Young physicians graduating from orthopedic residency and fellowship programs have many challenges ahead. They graduate with heavy debt into an uncertain healthcare environment and are expected to develop a new practice often without business or financial planning experience. With the pressure of loan repayment coupled with the zest to practice their newly-acquired skills, many surgeons enter into an employment agreement hastily and find themselves dissatisfied within a few years. For surgeons finishing orthopedic residencies, approximately 70 to 80 percent leaves their first job within two years of practice, and the rates are similar among neurological surgeons. The same is true among sports medicine subspecialists as well.
"Orthopedic surgeons are amongst the brightest and most talented physicians in all of medicine," says Michael Gleiber, MD, founder and CEO of Michael A. Gleiber, MD, PA, Spine Surgery, in Jupiter, Fla. "To match into orthopedic residency, one typically needs 240+ on their boards, research, strong letters of recommendation, and an unparalleled work ethic. These are bright folks who have typically gone to excellent medical schools and have received honors grades in the toughest med school rotations such as surgery and orthopedic surgery. So why are orthopedic fellows leaving practices so soon after joining them and what type of impact may this have on their careers in the short term?"
Here, 10 leaders in orthopedic and spine surgery discuss the biggest challenges young physicians face after training and how they can overcome them.
For more information about job interviews for young surgeons, see the article "10 Areas for Orthopedic & Spine Surgeons to Question in a Job Interview."
1. Visualize where you want to be in 15 years. As training comes to a close, orthopedic and spine surgeons must decide which career pathway best suits them: private practice, hospital employment, academic institution or another type of arrangement.
"Choose wisely between academics and private practice," says Dr. Gleiber. "If research has never interested you, and you have a strong business or entrepreneurial spirit — go into private practice."
There are several personal and professional factors to consider when making this decision, and visualizing an entire career can help young surgeons make the right choices early on to achieve those goals.
"It pays to look at your own career goals—what makes it interesting for you to be an orthopedic surgeon and where you see yourself in 15 years," says Jonathan P. Braman, MD, assistant professor and chief of shoulder surgery at the University of Minnesota in Minneapolis. He is also the shoulder and elbow resident education section leader of the department of orthopedic surgery. "Each choice has its own advantages and disadvantages."
Consider the responsibilities associated with each setting. "If you are interested in academic practice, it assumed that you have an interest in teaching residency and medical students and performing research, in addition to standard patient care," says Mladen Djurasovic, MD, clinical assistant professor in the department of orthopedic surgery at the University of Louisville and a spine surgeon with Norton Leatherman Spine Center in Louisville, Ky. "Financial rewards are often not as high as in private practice, but the professional satisfaction of training the next generation of orthopedic surgeons and helping advance the field through research can more than compensate for this. You have to decide if research and teaching are activities you truly enjoy and will want to pursue even in your spare time. If these activities excite you, then academic practice may be right for you."
Surgeons can also choose private practice in a single-specialty or multi-specialty group. Surgeons in an orthopedics specialty group can vary their practice or focus on a subspecialty. "These types of groups also lend themselves well to development of ancillary services, given the variety of practitioners," says Dr. Djurasovic. "These groups are also well positioned to market the fact that they can provide comprehensive musculoskeletal care to hospitals, payors, ect. Also, larger orthopedic groups may be better positioned to remain independent in an era of expanding consolidation of the healthcare market."
Single-specialty groups also foster an environment where more complex cases can be performed and surgeons have the advantage of discussing or performing cases with their partners dedicated to the same field.
Finally, surgeons can choose hospital employment, which is becoming more common among specialists including orthopedic surgeons. "Many groups are facing flat to declining reimbursement with continually raising overhead, threatening future financial stability," says Dr. Djurasovic. "Becoming employed by a hospital removes the burdens of managing the sometimes difficult business end of practice and allows you to just practice medicine. Also, hospital employment will generally lead to a rapid referral stream as the hospital will want to have its primary care practitioners direct referrals to you."
However, hospital practice can involve the loss of autonomy. "If managing your own business, and having total control of your office is important to you, [hospital employment] may not be the ideal practice setting," says Dr. Djurasovic. "You have to carefully consider the trade-offs."
There can be tremendous challenges associated with deciding which setting is right for each surgeon. "What is suited best for them is individualized," says James Andrews, MD, founder of Andrews Institute for Orthopaedics & Sports Medicine in Gulf Breeze, Fla., and a director of the Andrews Research & Education Institute fellows program. "We try to educate [our fellows] about making those choices during their fellowship program. As a matter of fact, we have several conferences during our Sports Medicine Conferences related to finding and securing a job with fair contracts. We also try to teach them about the pitfalls of searching for a job especially related to the actual job contracts."
2. Set strong goals and develop an action plan. Young orthopedic surgeons should set goals for themselves and develop an action plan for achieving them. "Having a written out goal is much more concrete than just thinking about it," says Dr. Sterling. "The best way to start off on a path to success is to create clear goals and create strategies to achieve those goals."
If the surgeon wants to spend time researching, then protected research time is essential; if the surgeon wants to limit their practice to spinal cases, join a practice where spine partners aren't at capacity, says Robert Sterling, MD, associate professor of orthopedics and residency program director in the department of orthopedics at the University of Maryland School of Medicine.
"Define your goals within five years and then in 10 years," says Keith Kenter, MD, associate professor of orthopedic surgery and director of the orthopedic surgery residency program at the University of Cincinnati. "Define a weekly schedule and stick to it despite a slow patient volume in office when beginning."
3. Develop a business sense. Physicians are well-trained in medical practice but often lack the knowledge and experience in business to fully grasp the undertaking of going into the business of medicine. "The pressures of developing a practice and being productive is completely new in the business of medicine and I think that more orthopedic surgeons are not well educated in the business aspect of joining the practice," says Dr. Sterling.
There are several resources that can help with this decision, including the American Academy of Orthopaedic Surgeons practice management pages and business of medicine programs. If you are negotiating a contract, know how to leverage your skills.
"You have no stronger negotiation leverage than when you are being recruited by the group," says William Levine, MD, professor of clinical orthopedic surgery, vice chairman of education in the department of orthopedic surgery, director of the sports medicine department of orthopedic surgery, associate director of the Center for Shoulder, Elbow and sports medicine and residency program director of orthopedic surgery at Columbia University Medical Center in New York City. "Do not feel shy about developing a reasonable 'wish list' of instruments, implants, personnel hires. Once you sign the contract your ability to negotiate further is virtually nil. It is also critical to have an experienced attorney preferably with medical contract background review your contract to advocate on your behalf."
4. Choose a location that you and your family like. Beginning practice as soon as possible and repaying your debt is very important, but you also want to make sure the location is right. Just because the practice is right and the contract looks good doesn't mean that you should jump at the opportunity without considering whether you and your family will be able to live there.
"Select a geographic area where you know you will be happy, even if the job does not work out," says Dr. Gleiber. "This way, your personal happiness will not be tied only to your success in the 'practice.'"
Finding a place where you can be happy is sometimes a challenge. "The biggest issue is developing the kind of practice they want," says Paul Tonetta, III, MD, professor and vice chairman of the department of orthopedic surgery and director of the orthopedic residency training program at Boston University School of Medicine and director of orthopedic trauma at Boston Medical Center. "[The] most important thing is to have realistic expectations of the desired practice and location and then match them. Many move as they take jobs and that they do not really want to be in an area… [so] they look around for better opportunities over time."
Your family is also important to consider in the equation. "Pick a part of the country where you and your family will be happy," says Daniel Riew, MD, professor of orthopedic surgery, chief of the surgical spine center and director of the Cervical Spine Institute at Washington University School of Medicine in St. Louis. "If your family is unhappy, you will be unhappy too."
5. Know how you will fit into the practice and community. When considering their first position, young surgeons should figure out how they will fit into the medical practice and community. "Understand what the needs of the group are and for wanting to hire you," says Dr. Levine. "Is it because there is a tremendous need for surgeons within your skill set (home run)? Is it because there is a need at a satellite office that they have opened (ground rule double)? Or is it because there is a perceived need at one of their sites and you are the best draft pick available (pop-up)?"
If the market is already saturated with surgeons of your skill set, that location may not be the best for you. "In my community (metro city) it took five years to build what I consider a successful practice," says Dr. Kenter. "I defined my niche and then practice sound orthopedic surgery. Patience is very important."
Ultimately, don't sell yourself short if you want to subspecialize in an area but the practice calls for a general orthopedic surgeon; it's likely you won't ever step out of that role.
"The pearls I think are finding a group or academic practice that has a niche/need for that subspecialty," says Dr. Tornetta. "Places that tell you they will work it out and you'll start out by doing general orthopedist don't work out as well."
6. Investigate practices recruiting you. Choosing your practice is like entering into a marriage because physicians often want to commit their entire careers to building a practice in one location. Before investing in a new practice or signing an employment contract, examine the practice thoroughly so you know the positives and negatives of the group.
"Talk to people in the group and even better is anyone who has recently left," says Dr. Sterling. "This is particularly insightful because those who have left will be more open about the problems. The caveat is that anyone who left under bad conditions will bias the discussion in the negative."
You can also speak with others in the community about the recruiting group. "Do due diligence on the practice by asking referring doctors, previous employees, former partners, current ancillary staff, community members about the reputation of the group," says Dr. Riew.
Examine the group's financial records as well to make sure the investment is good. "Make sure your prospective practice 'opens the books,'" says Dr. Gleiber. "If you are going to be joining a group and they are not forthcoming about income, partnership track, ancillary buy-ins, this is a red flag."
7. Rely on a support network. The transition from training into private practice has several personal as well as professional challenges, including buying a house, a car and balancing credit cards. Maintaining a solid network from training can help you throughout your career.
"Keep in touch with folks you trust from residency and fellowship," says Dr. Gleiber. "Every time you apply for privileges to a new hospital, you need to rely on these folks to support your application for attending privileges. These are also great to have available to discuss cases with."
Having a support network is especially true if you are moving to a new location and beginning practice with a new set of partners. In this case, you will need to build new relationships and trust your colleagues.
"The recent graduate must be willing to rely on support networks," says Dr. Djurasovic. "With regards to patient care, run cases past your partners and ask their advice. There is no substitute for experience, regardless of how good your training was. You are representing your practice and your outcomes will affect the entire practice. Your partners are invested in your succeeding, so let them help you. It is not a sign of weakness."
Young physicians should also focus on their family and make time for them. "With regards to family, make sure to create sufficient protected time to be involved in your kids' life and spend quality time with your spouse," says Dr. Djurasovic. "Remember that this transition is a difficult time for them as well, and they need your support and attention."
8. Include advancement details. All details of the arrangement should be thoroughly described in the contract. "Partnership track/tenure track needs to be clearly delineated and appreciated in advance so there are no surprises," says Bradford O. Parsons, MD, assistant professor of orthopedics at Mount Sinai School of Medicine in New York City. Agreement surrounding clinical support should also be spelled out in the contract, including the potential for physician assistants and others working within your practice.
When there are promises made, they should be made on paper. "I recommend [that] they get everything in writing and have it reviewed by a healthcare lawyer and understand everything in their employment agreement before they sign it," says Dr. Andrews.
Healthcare lawyers can help you write a solid contract and include an exit strategy in case the agreement doesn't work out. "Make sure you have an attorney well versed in the matters of physician employment," says Dr. Gleiber. "Choose an entrance and exit strategy — just in case."
9. Understand how compensation works and sign a tight contract. Young surgeons just finishing their training are in a huge amount of debt and compensation packages that include heavy signing bonuses are initially very attractive, but they may not be the best decision in the long run.
"Choose a practice based on final income potential and not initial pay/signing bonus," says Dr. Riew. "How is income divided in the group? If you are a hard worker, an equal pay for differential work will be unfair. Some degree of compensation based on amount of work performed is desirable. If a multispecialty group, be aware of equal split, given that different specialties have vastly different income potential."
After choosing the type of practice you want to pursue, check the different compensation arrangements for each institution and understand how the differences will impact your career.
"My academic practice is very different from the compensation and practice model of some of my academic colleagues," says Dr. Braman. "It pays to do your homework; have some understanding of how the compensation system works for orthopedic surgeons and ask the right questions of those who are offering you a job."
The compensation package should be competitive and something worth negotiating; the ideal package will often come with a hitch. "If an opportunity sounds too good to be true, IT IS!" says Dr. Gleiber. "It is better to find a position with a low starting salary where you are incentivized to develop a busy practice rather than the other way around. Once you reach your salary, generally you can begin collecting on percentage of the volume you bring in."
10. Be wary of signing bonuses. Signing bonuses can be very attractive to young physicians, but be aware of compensation down the line as well. "These negotiations are generally heavily weighted in favor of 'the practice' and not the fellow," says Dr. Gleiber. "The income guarantee is usually for one to two years and if the new surgeon does not make this money back by surgical productivity there exists the potential for a bad relationship to ensue between the senior partners or practice CEO and the new surgeon."
Physicians shouldn't look at this balloon salary and other perks as real income, rather as a loan. "Partnership tracks are generally based on fiscal productivity and it is quite difficult, if not impossible, to develop a mature practice where one can bring in significant amounts of revenue in a one to two year period," says Dr. Gleiber.
11. Always be available. It's important for orthopedic and spine surgeons just starting out to maintain as much availability as possible to build a strong patient base. In areas such as sports medicine, patients are often injured at Friday night or Saturday morning games; be available for them. You should also make time for referring physicians and work their patients in every time they call.
"The most effective tool in building a patient base initially is availability," says Dr. Levine. "While this is often spoken about and may seem like an old cliché, it is in fact crucial to early success. Being available and affable are truly critical—meeting referring physicians, nurse practitioners, office coordinators so they have a face with the name is also very important."
Referring physicians must know you are viable to take their patients. If you are unable to see their patients, they will stop calling. "What those referring doctors/practitioners want is to know that if they need to send a patient to you that the patient will be treated immediately and effectively so that the referring practice does not have to deal with 'bounce-back' patients," says Dr. Levine. "That only has to happen one time and you will likely not receive referrals from that group any longer."
Being available also means seeing patients regardless of their payor. "Take all payor mixes, do not turn anyone away," says Dr. Gleiber. "A patient that likes you will refer three to five others. On the contrary, one that does not may steer away six to eight from your practice."
Availability can also lead to growth within your private practice. "For new grads, being the hungry, willing to do anything attitude will also endear them to their partners as well as referring doctors, both orthopedic and primary care," says Dr. Parsons. "Nothing helps more than being willing to add on that patient at the last minute Friday afternoon in the summer when you are first starting out."
12. Make yourself known. There are many ways you can announce your arrival in a new community, both the medical and public communities. Once you have established your arrival, seek out referring physicians who are also relatively new and build a relationship with them.
"Every year, find out who has recently started in practice in your referral area," says Dr. Sterling. "Physicians just starting in practice have not yet established their referral patterns so you want to meet them early in their start. Arrange to meet them face to face and discuss your practice to make sure that when they refer patients, you communicate back to them your findings."
If you have a subspecialty practice, make sure to define the subspecialty and offer additional opportunities for the referring physician to become familiar with your practice. This can include educational opportunities and grand rounds with the referring physicians.
"During your fellowship, make sure that you develop a library of PowerPoint talks that you can give when you start in your new community," says Dr. Levine. "Basic talks for primary care practitioners, internists, pediatricians and physical therapists can be quite effective in introducing you to the community. Giving grand rounds talks to the department is another effective means of getting you exposure to a large number of people."
Another way break into the community is by covering youth sporting events. Orthopedic and sports medicine physicians often begin by volunteering with little league and may have the opportunity to work with more seasoned athletes as their careers progress. "I encourage [young physicians] to get involved in charity projects of the local community and also get involved in sports medicine for high schools, athletic clubs and the like," says Dr. Andrews. "If they think they can go into a community and all of a sudden become a team physician for the major university or the major professional football team without being at the bottom and building a base they will be truly discouraged and unsuccessful."
13. Develop a relationship with referring physicians. After becoming known and available to referring sources, develop the relationship further by sending follow-up messages about their patients. "Call all referring doctors for the first six months of your practice and make sure your notes are sent in a timely manner," says Dr. Riew.
It will take time and effort to build a patient base in the new community. "These young sports medicine physicians should be very cautious about building a patient base in the new community," says Dr. Andrews. "They should remember that a patient base is built one patient at a time and they would basically understand and accept the old saying 'crawl, walk and then run.'"
One of the biggest assets young physicians have as they begin to work with other medical professionals is their interpersonal skills.
"In building your practice, the most important factor is understanding that it is not your technical skills, but your interpersonal skills which build your practice," says Dr. Djurasovic. "Your referring doctors don't have a scoreboard, keeping track of your success rate with any given operation. What they understand is whether you are nice to them [and] communicate with them effectively (eg., returning phone calls, letters, ect.). As a specialist, you are trying to provide service to the doctors and patients who entrust others to your care. These are very different skills than what helped you advance as a resident or fellow. Remember, no matter how good you are, none of your patients or referring doctors will ever watch you do an operation. This is not how you are being judged."
14. Provide outstanding patient care. Word-of-mouth referrals are the most common patient-volume generator in private practices; happy patients will recommend you to their friends. "Think of each patient you see as the tip of a new triangle of patients you will see," says Dr. Riew. "If you make that person happy, they will, on average recommend you to two to three people, who will recommend you to two to three more people. On the other hand, if that patient doesn't like you, they will tell six to seven people about it and you have lost an entire group of patients."
When you are new in a community, people will be wondering about you. "If 98 percent say you are great, you will succeed," says Dr. Riew. "If less than 90 percent say you are great, you will be lucky to survive and flourish."
Patients should feel that all their questions are answered and that you care about them as individuals, and that you are doing your very best for them. "If you are genuine, they will sense it and trust you," says Dr. Riew. "They will tell their referring doctors about you."
15. Learn to make clinical decisions. Training physicians have the ability to work with experienced surgeons during their residencies and fellowships, but once they are in their own practices they are faced with making the final decision about their patients' care on their own. After starting out on their own, physicians must have the confidence to make those decisions — and make the right decisions — so they can build a successful practice without leaning on the expertise of others.
"This is a brand new level of responsibility that most have never experienced during training, and it can be quite stressful," says Dr. Djurasovic. "Often you have moved to a new part of the country and have to rebuild [your] social network from scratch."
However, there are ways physicians can prepare for this transition during their training. "One way to prepare for this transition is by confidently taking a stand during fellowship training. Even if you are simply seeing patients in a clinic, take a stand," says Dr. Braman. "Stating your diagnosis and treatment plan in front of your mentor has been shown to improve retention of knowledge and helps develop decision-making skills."
During training, Dr. Riew recommends surgeons take as many cases as possible to expand their experience. "Fellowship is for one year and that's the only year that you will have to get supervised training in advanced spine techniques," he says. "Spend as much time as possible learning during that year. In practice, no one will hand you a practice on a silver platter — you have to work for it."
This solitude can also be challenging for young physicians who are more familiar with the academic setting. "If you are going into a private practice environment it may be the first time in your medical training where you don't necessarily have a cadre of friends, colleagues and mentors to bounce ideas off and to ask for counsel and advice," says Dr. Levine. "'Academics is all you've actually ever known and can be sorely missed early in your private practice if you are in an isolated locale."
16. Mirror the best qualities of your mentor. While in training, Dr. Levine advises residents and fellows to analyze their attending mentors for their strongest attributes and incorporate them into their own practices.
"Be extremely critical in this process and then take the best attributes, qualities, practice tendencies of each of them and make those your own blueprint for success," says Dr. Levine. "Remember that each of those successful mentors started in the exact same place many years ago and have generally become successful due to their work ethic, interpersonal skills (usually) and clinical and surgical acumen."
17. Don't be afraid to ask questions. Whether you are finishing a residency or scrubbing in with a more experienced physician, young surgeons should pay close attention to their mentor's technique. Throughout the procedure, don't be afraid to ask questions about what the surgeon is doing to stay actively involved in the process.
"When actively involved, it becomes more apparent when the great surgeon is making decisions or subtle changes in technique based on what they see or do," says Dr. Braman. "Don't be afraid to ask questions. Many times, the mentor does not even know why they have done something and will have to find a way to articulate the rationale for something that simply comes naturally to them after years of practice. The experience is good for both of you."
It's important to take note of both routine and unique cases so you know how to handle both situations in your practice. "With standard cases, develop a systematic approach to the case so you can be efficient in your own practice," says Dr. Djurasovic. "Take notes on how to do non-routine cases; it may be a year or two until you see one in your own practice, so you want to be able to have notes to refer to."
After becoming familiar with a technique, the challenge is to maintain that skill set. "The most critical problem is the utilization and continuity of their talents in the first few years following their fellowship," says Dr. Andrews.
18. Work within solid indications. When you are just beginning your practice, follow strict indications and ensure patients will have the best outcomes. Differentiating between surgical and non-surgical care is a crucial part of building a successful orthopedic practice.
"[During training] pay special attention to non-operative care and surgical decision making when in clinic with your attending," says Dr. Djurasovic. "Sometimes the most difficult part of your first year or two in practice is not how to do the operation but deciding who to do it on, and which operation. This is what you learn in clinic — don't neglect this even though it may not be as exciting as the OR."
Remember to exhaust conservative care first before recommending surgery. "Be careful about being overly aggressive in terms of the treatment of vertebral fractures with cement augmentation," says Dr. Gleiber. "Non-operative treatment can be very effective in many cases, such as bracing."
Experience and clinical guidelines can help physicians make decisions about appropriate surgical candidates. "Be ethical and only operate on a condition if you would have an operation for it or you would recommend it to a family member," says Dr. Riew. "Being loose with surgical indications may make you busier in the short run but it will give you a lousy reputation and a poor practice in the long run. A slowly built practice with very strict indications will give you a good reputation and practice."
19. Refer complex cases to more experienced surgeons. Begin with simple cases that ensure the best operative results and know your limits. "Start out by doing simple cases and refer the difficult ones to more senior people in the community, or ask them to scrub in with you, if possible," says Dr. Riew. "That will ensure great operative results and prevent practice-killing complications."
If you have doubts, err on the side of caution. "Even though you have seen some very tough cases in fellowship doesn't mean you're necessarily ready to tackle them right out of the gates," says Dr. Gleiber. "Be careful who you seek out advice from as you will be judged in the community you serve. If you can find one or two more senior doctors to bounce cases off on and seek the advice from them or have them assist you in the OR, this will lend itself to building camaraderie, as well as improved outcomes. Do not do an operation if you cannot take care of the potential complication!"
20. Exercise humility. Humility is a key quality for professionals in any arena, including medicine. Physicians are sometimes perceived as arrogant or inaccessible, which drives people away. Exercising humility can foster important relationships with patients and colleagues that go a long way to building a strong practice.
"Treat all your staff, OR personnel with respect and kindness," says Dr. Riew. "Apologize if you make a mistake or lose your temper. They can be your biggest advocates or your worst PR disasters. Being condescending, losing your temper and being petty or mean is the surest way you have of insuring that people will speak ill of you or jump at the chance to testify against you in a malpractice case."
Young physicians can go a step further to let their colleagues know how much they appreciate their work. "As a new surgeon, you would be amazed at how quickly you can develop a great or sinking reputation in less than one month," says Dr. Gleiber. "In the OR, take your time and treat everyone from the scheduling desk to the scrub tech nicely. Let them know how much you appreciate their help."
Humility can win young physicians favor with established physicians in the area. This is especially true in competitive markets and among sports medicine physicians, who often have many of the same skills as general orthopedic surgeons with the added experience in sports medicine.
"I often tell my graduating fellows that they should be very humble and courteous when beginning," says Dr. Andrews. "Certainly don't try to glorify [yourselves] as newly trained sports medicine physicians, but go there with the anticipation of starting at the bottom and working your way up in general orthopedics and then gradually build your reputation. If they expect everything to be handed to them on a silver platter they will be greatly discouraged and if they boast their abilities by improper advertisement they will be shunned and denied by their peers."
21. Invest in your practice as soon as possible. Even though young orthopedic and spine surgeons coming out of training often have a pile of debt, it's important to invest in the practice as soon as possible. This is especially true when graduates have low interest rates, because investing in the practice can begin the process of accumulating income.
"Many of the graduates who are coming out now have loans at such low interest rates that it makes no sense to pay them off quickly," says Dr. Braman. "Money is better off in a different investment than coming off your student loans. For those who have higher loan rates, the best bet is to live simply and pay off the loans as quickly as possible. If you do so, then the burden is gone and the ability to have a more comfortable existence is improved."
Finding steadiness within a practice situation means financial stability will most likely follow. "[Young physicians] will certainly be more productive both in their careers as well as their economic situation if they can pick a place to practice and stay there and be productive there for many years rather than getting into a situation where they are divorcing their practice as 75 percent of the sports medicine physicians find themselves doing in two years," says Dr. Andrews. "It is really important for them to be in a community where they can become part of the community and gradually grow their practice."
However, make sure the practice is the right place for you. It isn't helpful to invest in a practice and then leave soon after. "Moving practices can have significant ramifications on one's personal life as well as professional growth," says Dr. Gleiber. "When one leaves a practice, this may set them back one to two years in preparing for the Oral Boards where cases must be collected over an almost two-year time frame. Additionally, the new surgeon now has to move — if there is a restrictive covenant — to a new geographic area and start building his/her practice all over again. It can also lead to strife in one's personal life with their significant other or spouse and/or children."
22. Live within your means. During the first few years of practice, young physicians are often still paying off their medical school debt. Don't accumulate more debt by overspending on luxury items; instead, live frugally for a few more years to achieve financial stability.
"As for managing debt, the key in my mind is living within your means when you start out so you can aggressively pay down debt," says Dr. Parsons. "Then once your head is above water and your practice is off and running you can enjoy life!"
New physicians who make large purchases based on their potential income may also find themselves in trouble. "Recent graduates should consider the probability those reimbursements to physicians will likely decline in the future," says Dr. Djurasovic. "How much is difficult to predict, but you will certainly make your situation more stressful if you spend your first few years of practice committing to a large mortgage, financing expensive cars, joining country clubs, ect. You may find yourself five years into practice facing a number of large fixed payments every month in addition to your medical school debt. Consider not changing your standard of living for the first two to three years of your practice."
Even after paying off your debt, it's important save and avoid spending more than what you have. ""If you start out by getting into more debt by buying a big home, new expensive car and other 'toys' to reward yourself for all those years of doing without, you will probably feel poor for a long time," says Dr. Riew. "If that's how you manage money, you may never get to a point where you have enough set aside to be comfortable. If you live within your means, after 15-25 years of working, you should have enough set aside to pay for your kids' education and even retire, if need be."
23. Hire a financial planner. It's important to know what programs are available for dealing with student loan debt and the accumulation of wealth. Financial planners can help young physicians set their affairs and manage their finances appropriately. "Most people should have a good financial planner," says Dr. Sterling. "Ask your partners who they use and interview them. Most surgeons don't have the knowledge or time to learn all of this and so trying to manage this on one's own is extremely difficult."
One of the things young physicians should consider is their future investments. "Pay off your debt with intense focus and then begin to build an investment portfolio," says Dr. Djurasovic. "Then you can start to reward yourself a little for all your hard work. With regards to investing, always keep in mind the enormous power of compounding and how time dependent this is. Investments set aside at age 35 are much more valuable than similar investments made at age 55."
Dr. Kenter and his wife also worked with a financial advisor to achieve stability. "We met with our financial advisor and defined what our goals were to be then balanced our assets, investments accordingly," he says. "We now have an outstanding retirement plan and almost enough money for our three children's education."
24. Enter into a loan forgiveness program. There are ways young physicians can have their loans forgiven, such as working for not-for-profit hospitals or in underserved areas. "The AAMC has some resources for learning about this in the Financial Information, Resources, Services and tools section," says Dr. Sterling. "This includes a list of the loan forgiveness programs available, a presentation on loan repayment and some other useful things."
25. Plan for retirement. Most physicians just coming out of fellowships are eager to begin their practice and pay off medical school debt — a huge undertaking. However, surgeons should not overlook retirement planning. Begin setting money aside for retirement as soon as possible, says Dr. Braman.
"The minute that the debt is gone, begin saving for retirement," says Dr. Braman. "Most of us are way behind the curve as we did not plan for retirement while students and residents. Consequently, we need to contribute aggressively when there is room in our incomes or we will never catch up."
Lead contributor:
Michael Gleiber, MD, founder and CEO of Michael A. Gleiber, MD, PA, Spine Surgery
Contributors:
James Andrews, MD, founder of Andrews Institute for Orthopaedics & Sports Medicine in Gulf Breeze, Fla., and a director of the Andrews Research & Education Institute fellows program
Jonathan P. Braman, MD, assistant professor and chief of shoulder surgery, shoulder and elbow resident education section leader of the department of orthopedic surgery, at the University of Minnesota, Minneapolis
Mladen Djurasovic, MD, clinical assistant professor, department of orthopedic surgery at the University of Louisville and spine surgeon, Norton Leatherman Spine Center, Louisville, Ky.
Keith Kenter, MD, associate professor of orthopedic surgery and director of the orthopedic surgery residency program at the University of Cincinnati
William Levine, MD, professor of clinical orthopedic surgery, vice chairman of education in the department of orthopedic surgery, director of the sports medicine department of orthopedic surgery, associate director of the Center for Shoulder, Elbow and sports medicine and residency program director of orthopedic surgery, Columbia University Medical Center in New York City
Bradford O. Parsons, MD, assistant professor of orthopedics, Mount Sinai School of Medicine, New York City.
K. Daniel Riew, MD, Mildred B. Simon Distinguished Professor of Orthopedic Surgery, Professor of Neurological Surgery, Chief, Cervical Spine Surgery, Washington University Orthopedics, Washington University School of Medicine, St. Louis
Robert Sterling, MD, associate professor of orthopedics and residency program director in the department of orthopedics, University of Maryland School of Medicine, Baltimore
Paul Tonetta, III, MD, professor and vice chairman of the department of orthopedic surgery and director of the orthopedic residency training program, Boston University School of Medicine, director of orthopedic trauma, Boston Medical Center.
More Articles on Orthopedic Surgery:
10 Spine Surgeons on Factors of Spinal Fusion's 137% Jump in 10 Years
6 Steps to Prepare for the Future of Outpatient Spine Surgery
4 Tips for the Entrepreneurial Business-Minded Spine Surgeon
"Orthopedic surgeons are amongst the brightest and most talented physicians in all of medicine," says Michael Gleiber, MD, founder and CEO of Michael A. Gleiber, MD, PA, Spine Surgery, in Jupiter, Fla. "To match into orthopedic residency, one typically needs 240+ on their boards, research, strong letters of recommendation, and an unparalleled work ethic. These are bright folks who have typically gone to excellent medical schools and have received honors grades in the toughest med school rotations such as surgery and orthopedic surgery. So why are orthopedic fellows leaving practices so soon after joining them and what type of impact may this have on their careers in the short term?"
Here, 10 leaders in orthopedic and spine surgery discuss the biggest challenges young physicians face after training and how they can overcome them.
For more information about job interviews for young surgeons, see the article "10 Areas for Orthopedic & Spine Surgeons to Question in a Job Interview."
Choosing a practice
1. Visualize where you want to be in 15 years. As training comes to a close, orthopedic and spine surgeons must decide which career pathway best suits them: private practice, hospital employment, academic institution or another type of arrangement.
"Choose wisely between academics and private practice," says Dr. Gleiber. "If research has never interested you, and you have a strong business or entrepreneurial spirit — go into private practice."
There are several personal and professional factors to consider when making this decision, and visualizing an entire career can help young surgeons make the right choices early on to achieve those goals.
"It pays to look at your own career goals—what makes it interesting for you to be an orthopedic surgeon and where you see yourself in 15 years," says Jonathan P. Braman, MD, assistant professor and chief of shoulder surgery at the University of Minnesota in Minneapolis. He is also the shoulder and elbow resident education section leader of the department of orthopedic surgery. "Each choice has its own advantages and disadvantages."
Consider the responsibilities associated with each setting. "If you are interested in academic practice, it assumed that you have an interest in teaching residency and medical students and performing research, in addition to standard patient care," says Mladen Djurasovic, MD, clinical assistant professor in the department of orthopedic surgery at the University of Louisville and a spine surgeon with Norton Leatherman Spine Center in Louisville, Ky. "Financial rewards are often not as high as in private practice, but the professional satisfaction of training the next generation of orthopedic surgeons and helping advance the field through research can more than compensate for this. You have to decide if research and teaching are activities you truly enjoy and will want to pursue even in your spare time. If these activities excite you, then academic practice may be right for you."
Surgeons can also choose private practice in a single-specialty or multi-specialty group. Surgeons in an orthopedics specialty group can vary their practice or focus on a subspecialty. "These types of groups also lend themselves well to development of ancillary services, given the variety of practitioners," says Dr. Djurasovic. "These groups are also well positioned to market the fact that they can provide comprehensive musculoskeletal care to hospitals, payors, ect. Also, larger orthopedic groups may be better positioned to remain independent in an era of expanding consolidation of the healthcare market."
Single-specialty groups also foster an environment where more complex cases can be performed and surgeons have the advantage of discussing or performing cases with their partners dedicated to the same field.
Finally, surgeons can choose hospital employment, which is becoming more common among specialists including orthopedic surgeons. "Many groups are facing flat to declining reimbursement with continually raising overhead, threatening future financial stability," says Dr. Djurasovic. "Becoming employed by a hospital removes the burdens of managing the sometimes difficult business end of practice and allows you to just practice medicine. Also, hospital employment will generally lead to a rapid referral stream as the hospital will want to have its primary care practitioners direct referrals to you."
However, hospital practice can involve the loss of autonomy. "If managing your own business, and having total control of your office is important to you, [hospital employment] may not be the ideal practice setting," says Dr. Djurasovic. "You have to carefully consider the trade-offs."
There can be tremendous challenges associated with deciding which setting is right for each surgeon. "What is suited best for them is individualized," says James Andrews, MD, founder of Andrews Institute for Orthopaedics & Sports Medicine in Gulf Breeze, Fla., and a director of the Andrews Research & Education Institute fellows program. "We try to educate [our fellows] about making those choices during their fellowship program. As a matter of fact, we have several conferences during our Sports Medicine Conferences related to finding and securing a job with fair contracts. We also try to teach them about the pitfalls of searching for a job especially related to the actual job contracts."
2. Set strong goals and develop an action plan. Young orthopedic surgeons should set goals for themselves and develop an action plan for achieving them. "Having a written out goal is much more concrete than just thinking about it," says Dr. Sterling. "The best way to start off on a path to success is to create clear goals and create strategies to achieve those goals."
If the surgeon wants to spend time researching, then protected research time is essential; if the surgeon wants to limit their practice to spinal cases, join a practice where spine partners aren't at capacity, says Robert Sterling, MD, associate professor of orthopedics and residency program director in the department of orthopedics at the University of Maryland School of Medicine.
"Define your goals within five years and then in 10 years," says Keith Kenter, MD, associate professor of orthopedic surgery and director of the orthopedic surgery residency program at the University of Cincinnati. "Define a weekly schedule and stick to it despite a slow patient volume in office when beginning."
3. Develop a business sense. Physicians are well-trained in medical practice but often lack the knowledge and experience in business to fully grasp the undertaking of going into the business of medicine. "The pressures of developing a practice and being productive is completely new in the business of medicine and I think that more orthopedic surgeons are not well educated in the business aspect of joining the practice," says Dr. Sterling.
There are several resources that can help with this decision, including the American Academy of Orthopaedic Surgeons practice management pages and business of medicine programs. If you are negotiating a contract, know how to leverage your skills.
"You have no stronger negotiation leverage than when you are being recruited by the group," says William Levine, MD, professor of clinical orthopedic surgery, vice chairman of education in the department of orthopedic surgery, director of the sports medicine department of orthopedic surgery, associate director of the Center for Shoulder, Elbow and sports medicine and residency program director of orthopedic surgery at Columbia University Medical Center in New York City. "Do not feel shy about developing a reasonable 'wish list' of instruments, implants, personnel hires. Once you sign the contract your ability to negotiate further is virtually nil. It is also critical to have an experienced attorney preferably with medical contract background review your contract to advocate on your behalf."
4. Choose a location that you and your family like. Beginning practice as soon as possible and repaying your debt is very important, but you also want to make sure the location is right. Just because the practice is right and the contract looks good doesn't mean that you should jump at the opportunity without considering whether you and your family will be able to live there.
"Select a geographic area where you know you will be happy, even if the job does not work out," says Dr. Gleiber. "This way, your personal happiness will not be tied only to your success in the 'practice.'"
Finding a place where you can be happy is sometimes a challenge. "The biggest issue is developing the kind of practice they want," says Paul Tonetta, III, MD, professor and vice chairman of the department of orthopedic surgery and director of the orthopedic residency training program at Boston University School of Medicine and director of orthopedic trauma at Boston Medical Center. "[The] most important thing is to have realistic expectations of the desired practice and location and then match them. Many move as they take jobs and that they do not really want to be in an area… [so] they look around for better opportunities over time."
Your family is also important to consider in the equation. "Pick a part of the country where you and your family will be happy," says Daniel Riew, MD, professor of orthopedic surgery, chief of the surgical spine center and director of the Cervical Spine Institute at Washington University School of Medicine in St. Louis. "If your family is unhappy, you will be unhappy too."
5. Know how you will fit into the practice and community. When considering their first position, young surgeons should figure out how they will fit into the medical practice and community. "Understand what the needs of the group are and for wanting to hire you," says Dr. Levine. "Is it because there is a tremendous need for surgeons within your skill set (home run)? Is it because there is a need at a satellite office that they have opened (ground rule double)? Or is it because there is a perceived need at one of their sites and you are the best draft pick available (pop-up)?"
If the market is already saturated with surgeons of your skill set, that location may not be the best for you. "In my community (metro city) it took five years to build what I consider a successful practice," says Dr. Kenter. "I defined my niche and then practice sound orthopedic surgery. Patience is very important."
Ultimately, don't sell yourself short if you want to subspecialize in an area but the practice calls for a general orthopedic surgeon; it's likely you won't ever step out of that role.
"The pearls I think are finding a group or academic practice that has a niche/need for that subspecialty," says Dr. Tornetta. "Places that tell you they will work it out and you'll start out by doing general orthopedist don't work out as well."
6. Investigate practices recruiting you. Choosing your practice is like entering into a marriage because physicians often want to commit their entire careers to building a practice in one location. Before investing in a new practice or signing an employment contract, examine the practice thoroughly so you know the positives and negatives of the group.
"Talk to people in the group and even better is anyone who has recently left," says Dr. Sterling. "This is particularly insightful because those who have left will be more open about the problems. The caveat is that anyone who left under bad conditions will bias the discussion in the negative."
You can also speak with others in the community about the recruiting group. "Do due diligence on the practice by asking referring doctors, previous employees, former partners, current ancillary staff, community members about the reputation of the group," says Dr. Riew.
Examine the group's financial records as well to make sure the investment is good. "Make sure your prospective practice 'opens the books,'" says Dr. Gleiber. "If you are going to be joining a group and they are not forthcoming about income, partnership track, ancillary buy-ins, this is a red flag."
7. Rely on a support network. The transition from training into private practice has several personal as well as professional challenges, including buying a house, a car and balancing credit cards. Maintaining a solid network from training can help you throughout your career.
"Keep in touch with folks you trust from residency and fellowship," says Dr. Gleiber. "Every time you apply for privileges to a new hospital, you need to rely on these folks to support your application for attending privileges. These are also great to have available to discuss cases with."
Having a support network is especially true if you are moving to a new location and beginning practice with a new set of partners. In this case, you will need to build new relationships and trust your colleagues.
"The recent graduate must be willing to rely on support networks," says Dr. Djurasovic. "With regards to patient care, run cases past your partners and ask their advice. There is no substitute for experience, regardless of how good your training was. You are representing your practice and your outcomes will affect the entire practice. Your partners are invested in your succeeding, so let them help you. It is not a sign of weakness."
Young physicians should also focus on their family and make time for them. "With regards to family, make sure to create sufficient protected time to be involved in your kids' life and spend quality time with your spouse," says Dr. Djurasovic. "Remember that this transition is a difficult time for them as well, and they need your support and attention."
Signing the contract
8. Include advancement details. All details of the arrangement should be thoroughly described in the contract. "Partnership track/tenure track needs to be clearly delineated and appreciated in advance so there are no surprises," says Bradford O. Parsons, MD, assistant professor of orthopedics at Mount Sinai School of Medicine in New York City. Agreement surrounding clinical support should also be spelled out in the contract, including the potential for physician assistants and others working within your practice.
When there are promises made, they should be made on paper. "I recommend [that] they get everything in writing and have it reviewed by a healthcare lawyer and understand everything in their employment agreement before they sign it," says Dr. Andrews.
Healthcare lawyers can help you write a solid contract and include an exit strategy in case the agreement doesn't work out. "Make sure you have an attorney well versed in the matters of physician employment," says Dr. Gleiber. "Choose an entrance and exit strategy — just in case."
9. Understand how compensation works and sign a tight contract. Young surgeons just finishing their training are in a huge amount of debt and compensation packages that include heavy signing bonuses are initially very attractive, but they may not be the best decision in the long run.
"Choose a practice based on final income potential and not initial pay/signing bonus," says Dr. Riew. "How is income divided in the group? If you are a hard worker, an equal pay for differential work will be unfair. Some degree of compensation based on amount of work performed is desirable. If a multispecialty group, be aware of equal split, given that different specialties have vastly different income potential."
After choosing the type of practice you want to pursue, check the different compensation arrangements for each institution and understand how the differences will impact your career.
"My academic practice is very different from the compensation and practice model of some of my academic colleagues," says Dr. Braman. "It pays to do your homework; have some understanding of how the compensation system works for orthopedic surgeons and ask the right questions of those who are offering you a job."
The compensation package should be competitive and something worth negotiating; the ideal package will often come with a hitch. "If an opportunity sounds too good to be true, IT IS!" says Dr. Gleiber. "It is better to find a position with a low starting salary where you are incentivized to develop a busy practice rather than the other way around. Once you reach your salary, generally you can begin collecting on percentage of the volume you bring in."
10. Be wary of signing bonuses. Signing bonuses can be very attractive to young physicians, but be aware of compensation down the line as well. "These negotiations are generally heavily weighted in favor of 'the practice' and not the fellow," says Dr. Gleiber. "The income guarantee is usually for one to two years and if the new surgeon does not make this money back by surgical productivity there exists the potential for a bad relationship to ensue between the senior partners or practice CEO and the new surgeon."
Physicians shouldn't look at this balloon salary and other perks as real income, rather as a loan. "Partnership tracks are generally based on fiscal productivity and it is quite difficult, if not impossible, to develop a mature practice where one can bring in significant amounts of revenue in a one to two year period," says Dr. Gleiber.
Building a patient base
11. Always be available. It's important for orthopedic and spine surgeons just starting out to maintain as much availability as possible to build a strong patient base. In areas such as sports medicine, patients are often injured at Friday night or Saturday morning games; be available for them. You should also make time for referring physicians and work their patients in every time they call.
"The most effective tool in building a patient base initially is availability," says Dr. Levine. "While this is often spoken about and may seem like an old cliché, it is in fact crucial to early success. Being available and affable are truly critical—meeting referring physicians, nurse practitioners, office coordinators so they have a face with the name is also very important."
Referring physicians must know you are viable to take their patients. If you are unable to see their patients, they will stop calling. "What those referring doctors/practitioners want is to know that if they need to send a patient to you that the patient will be treated immediately and effectively so that the referring practice does not have to deal with 'bounce-back' patients," says Dr. Levine. "That only has to happen one time and you will likely not receive referrals from that group any longer."
Being available also means seeing patients regardless of their payor. "Take all payor mixes, do not turn anyone away," says Dr. Gleiber. "A patient that likes you will refer three to five others. On the contrary, one that does not may steer away six to eight from your practice."
Availability can also lead to growth within your private practice. "For new grads, being the hungry, willing to do anything attitude will also endear them to their partners as well as referring doctors, both orthopedic and primary care," says Dr. Parsons. "Nothing helps more than being willing to add on that patient at the last minute Friday afternoon in the summer when you are first starting out."
12. Make yourself known. There are many ways you can announce your arrival in a new community, both the medical and public communities. Once you have established your arrival, seek out referring physicians who are also relatively new and build a relationship with them.
"Every year, find out who has recently started in practice in your referral area," says Dr. Sterling. "Physicians just starting in practice have not yet established their referral patterns so you want to meet them early in their start. Arrange to meet them face to face and discuss your practice to make sure that when they refer patients, you communicate back to them your findings."
If you have a subspecialty practice, make sure to define the subspecialty and offer additional opportunities for the referring physician to become familiar with your practice. This can include educational opportunities and grand rounds with the referring physicians.
"During your fellowship, make sure that you develop a library of PowerPoint talks that you can give when you start in your new community," says Dr. Levine. "Basic talks for primary care practitioners, internists, pediatricians and physical therapists can be quite effective in introducing you to the community. Giving grand rounds talks to the department is another effective means of getting you exposure to a large number of people."
Another way break into the community is by covering youth sporting events. Orthopedic and sports medicine physicians often begin by volunteering with little league and may have the opportunity to work with more seasoned athletes as their careers progress. "I encourage [young physicians] to get involved in charity projects of the local community and also get involved in sports medicine for high schools, athletic clubs and the like," says Dr. Andrews. "If they think they can go into a community and all of a sudden become a team physician for the major university or the major professional football team without being at the bottom and building a base they will be truly discouraged and unsuccessful."
13. Develop a relationship with referring physicians. After becoming known and available to referring sources, develop the relationship further by sending follow-up messages about their patients. "Call all referring doctors for the first six months of your practice and make sure your notes are sent in a timely manner," says Dr. Riew.
It will take time and effort to build a patient base in the new community. "These young sports medicine physicians should be very cautious about building a patient base in the new community," says Dr. Andrews. "They should remember that a patient base is built one patient at a time and they would basically understand and accept the old saying 'crawl, walk and then run.'"
One of the biggest assets young physicians have as they begin to work with other medical professionals is their interpersonal skills.
"In building your practice, the most important factor is understanding that it is not your technical skills, but your interpersonal skills which build your practice," says Dr. Djurasovic. "Your referring doctors don't have a scoreboard, keeping track of your success rate with any given operation. What they understand is whether you are nice to them [and] communicate with them effectively (eg., returning phone calls, letters, ect.). As a specialist, you are trying to provide service to the doctors and patients who entrust others to your care. These are very different skills than what helped you advance as a resident or fellow. Remember, no matter how good you are, none of your patients or referring doctors will ever watch you do an operation. This is not how you are being judged."
14. Provide outstanding patient care. Word-of-mouth referrals are the most common patient-volume generator in private practices; happy patients will recommend you to their friends. "Think of each patient you see as the tip of a new triangle of patients you will see," says Dr. Riew. "If you make that person happy, they will, on average recommend you to two to three people, who will recommend you to two to three more people. On the other hand, if that patient doesn't like you, they will tell six to seven people about it and you have lost an entire group of patients."
When you are new in a community, people will be wondering about you. "If 98 percent say you are great, you will succeed," says Dr. Riew. "If less than 90 percent say you are great, you will be lucky to survive and flourish."
Patients should feel that all their questions are answered and that you care about them as individuals, and that you are doing your very best for them. "If you are genuine, they will sense it and trust you," says Dr. Riew. "They will tell their referring doctors about you."
Honing technique
15. Learn to make clinical decisions. Training physicians have the ability to work with experienced surgeons during their residencies and fellowships, but once they are in their own practices they are faced with making the final decision about their patients' care on their own. After starting out on their own, physicians must have the confidence to make those decisions — and make the right decisions — so they can build a successful practice without leaning on the expertise of others.
"This is a brand new level of responsibility that most have never experienced during training, and it can be quite stressful," says Dr. Djurasovic. "Often you have moved to a new part of the country and have to rebuild [your] social network from scratch."
However, there are ways physicians can prepare for this transition during their training. "One way to prepare for this transition is by confidently taking a stand during fellowship training. Even if you are simply seeing patients in a clinic, take a stand," says Dr. Braman. "Stating your diagnosis and treatment plan in front of your mentor has been shown to improve retention of knowledge and helps develop decision-making skills."
During training, Dr. Riew recommends surgeons take as many cases as possible to expand their experience. "Fellowship is for one year and that's the only year that you will have to get supervised training in advanced spine techniques," he says. "Spend as much time as possible learning during that year. In practice, no one will hand you a practice on a silver platter — you have to work for it."
This solitude can also be challenging for young physicians who are more familiar with the academic setting. "If you are going into a private practice environment it may be the first time in your medical training where you don't necessarily have a cadre of friends, colleagues and mentors to bounce ideas off and to ask for counsel and advice," says Dr. Levine. "'Academics is all you've actually ever known and can be sorely missed early in your private practice if you are in an isolated locale."
16. Mirror the best qualities of your mentor. While in training, Dr. Levine advises residents and fellows to analyze their attending mentors for their strongest attributes and incorporate them into their own practices.
"Be extremely critical in this process and then take the best attributes, qualities, practice tendencies of each of them and make those your own blueprint for success," says Dr. Levine. "Remember that each of those successful mentors started in the exact same place many years ago and have generally become successful due to their work ethic, interpersonal skills (usually) and clinical and surgical acumen."
17. Don't be afraid to ask questions. Whether you are finishing a residency or scrubbing in with a more experienced physician, young surgeons should pay close attention to their mentor's technique. Throughout the procedure, don't be afraid to ask questions about what the surgeon is doing to stay actively involved in the process.
"When actively involved, it becomes more apparent when the great surgeon is making decisions or subtle changes in technique based on what they see or do," says Dr. Braman. "Don't be afraid to ask questions. Many times, the mentor does not even know why they have done something and will have to find a way to articulate the rationale for something that simply comes naturally to them after years of practice. The experience is good for both of you."
It's important to take note of both routine and unique cases so you know how to handle both situations in your practice. "With standard cases, develop a systematic approach to the case so you can be efficient in your own practice," says Dr. Djurasovic. "Take notes on how to do non-routine cases; it may be a year or two until you see one in your own practice, so you want to be able to have notes to refer to."
After becoming familiar with a technique, the challenge is to maintain that skill set. "The most critical problem is the utilization and continuity of their talents in the first few years following their fellowship," says Dr. Andrews.
18. Work within solid indications. When you are just beginning your practice, follow strict indications and ensure patients will have the best outcomes. Differentiating between surgical and non-surgical care is a crucial part of building a successful orthopedic practice.
"[During training] pay special attention to non-operative care and surgical decision making when in clinic with your attending," says Dr. Djurasovic. "Sometimes the most difficult part of your first year or two in practice is not how to do the operation but deciding who to do it on, and which operation. This is what you learn in clinic — don't neglect this even though it may not be as exciting as the OR."
Remember to exhaust conservative care first before recommending surgery. "Be careful about being overly aggressive in terms of the treatment of vertebral fractures with cement augmentation," says Dr. Gleiber. "Non-operative treatment can be very effective in many cases, such as bracing."
Experience and clinical guidelines can help physicians make decisions about appropriate surgical candidates. "Be ethical and only operate on a condition if you would have an operation for it or you would recommend it to a family member," says Dr. Riew. "Being loose with surgical indications may make you busier in the short run but it will give you a lousy reputation and a poor practice in the long run. A slowly built practice with very strict indications will give you a good reputation and practice."
19. Refer complex cases to more experienced surgeons. Begin with simple cases that ensure the best operative results and know your limits. "Start out by doing simple cases and refer the difficult ones to more senior people in the community, or ask them to scrub in with you, if possible," says Dr. Riew. "That will ensure great operative results and prevent practice-killing complications."
If you have doubts, err on the side of caution. "Even though you have seen some very tough cases in fellowship doesn't mean you're necessarily ready to tackle them right out of the gates," says Dr. Gleiber. "Be careful who you seek out advice from as you will be judged in the community you serve. If you can find one or two more senior doctors to bounce cases off on and seek the advice from them or have them assist you in the OR, this will lend itself to building camaraderie, as well as improved outcomes. Do not do an operation if you cannot take care of the potential complication!"
20. Exercise humility. Humility is a key quality for professionals in any arena, including medicine. Physicians are sometimes perceived as arrogant or inaccessible, which drives people away. Exercising humility can foster important relationships with patients and colleagues that go a long way to building a strong practice.
"Treat all your staff, OR personnel with respect and kindness," says Dr. Riew. "Apologize if you make a mistake or lose your temper. They can be your biggest advocates or your worst PR disasters. Being condescending, losing your temper and being petty or mean is the surest way you have of insuring that people will speak ill of you or jump at the chance to testify against you in a malpractice case."
Young physicians can go a step further to let their colleagues know how much they appreciate their work. "As a new surgeon, you would be amazed at how quickly you can develop a great or sinking reputation in less than one month," says Dr. Gleiber. "In the OR, take your time and treat everyone from the scheduling desk to the scrub tech nicely. Let them know how much you appreciate their help."
Humility can win young physicians favor with established physicians in the area. This is especially true in competitive markets and among sports medicine physicians, who often have many of the same skills as general orthopedic surgeons with the added experience in sports medicine.
"I often tell my graduating fellows that they should be very humble and courteous when beginning," says Dr. Andrews. "Certainly don't try to glorify [yourselves] as newly trained sports medicine physicians, but go there with the anticipation of starting at the bottom and working your way up in general orthopedics and then gradually build your reputation. If they expect everything to be handed to them on a silver platter they will be greatly discouraged and if they boast their abilities by improper advertisement they will be shunned and denied by their peers."
Achieving financial stability
21. Invest in your practice as soon as possible. Even though young orthopedic and spine surgeons coming out of training often have a pile of debt, it's important to invest in the practice as soon as possible. This is especially true when graduates have low interest rates, because investing in the practice can begin the process of accumulating income.
"Many of the graduates who are coming out now have loans at such low interest rates that it makes no sense to pay them off quickly," says Dr. Braman. "Money is better off in a different investment than coming off your student loans. For those who have higher loan rates, the best bet is to live simply and pay off the loans as quickly as possible. If you do so, then the burden is gone and the ability to have a more comfortable existence is improved."
Finding steadiness within a practice situation means financial stability will most likely follow. "[Young physicians] will certainly be more productive both in their careers as well as their economic situation if they can pick a place to practice and stay there and be productive there for many years rather than getting into a situation where they are divorcing their practice as 75 percent of the sports medicine physicians find themselves doing in two years," says Dr. Andrews. "It is really important for them to be in a community where they can become part of the community and gradually grow their practice."
However, make sure the practice is the right place for you. It isn't helpful to invest in a practice and then leave soon after. "Moving practices can have significant ramifications on one's personal life as well as professional growth," says Dr. Gleiber. "When one leaves a practice, this may set them back one to two years in preparing for the Oral Boards where cases must be collected over an almost two-year time frame. Additionally, the new surgeon now has to move — if there is a restrictive covenant — to a new geographic area and start building his/her practice all over again. It can also lead to strife in one's personal life with their significant other or spouse and/or children."
22. Live within your means. During the first few years of practice, young physicians are often still paying off their medical school debt. Don't accumulate more debt by overspending on luxury items; instead, live frugally for a few more years to achieve financial stability.
"As for managing debt, the key in my mind is living within your means when you start out so you can aggressively pay down debt," says Dr. Parsons. "Then once your head is above water and your practice is off and running you can enjoy life!"
New physicians who make large purchases based on their potential income may also find themselves in trouble. "Recent graduates should consider the probability those reimbursements to physicians will likely decline in the future," says Dr. Djurasovic. "How much is difficult to predict, but you will certainly make your situation more stressful if you spend your first few years of practice committing to a large mortgage, financing expensive cars, joining country clubs, ect. You may find yourself five years into practice facing a number of large fixed payments every month in addition to your medical school debt. Consider not changing your standard of living for the first two to three years of your practice."
Even after paying off your debt, it's important save and avoid spending more than what you have. ""If you start out by getting into more debt by buying a big home, new expensive car and other 'toys' to reward yourself for all those years of doing without, you will probably feel poor for a long time," says Dr. Riew. "If that's how you manage money, you may never get to a point where you have enough set aside to be comfortable. If you live within your means, after 15-25 years of working, you should have enough set aside to pay for your kids' education and even retire, if need be."
23. Hire a financial planner. It's important to know what programs are available for dealing with student loan debt and the accumulation of wealth. Financial planners can help young physicians set their affairs and manage their finances appropriately. "Most people should have a good financial planner," says Dr. Sterling. "Ask your partners who they use and interview them. Most surgeons don't have the knowledge or time to learn all of this and so trying to manage this on one's own is extremely difficult."
One of the things young physicians should consider is their future investments. "Pay off your debt with intense focus and then begin to build an investment portfolio," says Dr. Djurasovic. "Then you can start to reward yourself a little for all your hard work. With regards to investing, always keep in mind the enormous power of compounding and how time dependent this is. Investments set aside at age 35 are much more valuable than similar investments made at age 55."
Dr. Kenter and his wife also worked with a financial advisor to achieve stability. "We met with our financial advisor and defined what our goals were to be then balanced our assets, investments accordingly," he says. "We now have an outstanding retirement plan and almost enough money for our three children's education."
24. Enter into a loan forgiveness program. There are ways young physicians can have their loans forgiven, such as working for not-for-profit hospitals or in underserved areas. "The AAMC has some resources for learning about this in the Financial Information, Resources, Services and tools section," says Dr. Sterling. "This includes a list of the loan forgiveness programs available, a presentation on loan repayment and some other useful things."
25. Plan for retirement. Most physicians just coming out of fellowships are eager to begin their practice and pay off medical school debt — a huge undertaking. However, surgeons should not overlook retirement planning. Begin setting money aside for retirement as soon as possible, says Dr. Braman.
"The minute that the debt is gone, begin saving for retirement," says Dr. Braman. "Most of us are way behind the curve as we did not plan for retirement while students and residents. Consequently, we need to contribute aggressively when there is room in our incomes or we will never catch up."
Lead contributor:
Michael Gleiber, MD, founder and CEO of Michael A. Gleiber, MD, PA, Spine Surgery
Contributors:
James Andrews, MD, founder of Andrews Institute for Orthopaedics & Sports Medicine in Gulf Breeze, Fla., and a director of the Andrews Research & Education Institute fellows program
Jonathan P. Braman, MD, assistant professor and chief of shoulder surgery, shoulder and elbow resident education section leader of the department of orthopedic surgery, at the University of Minnesota, Minneapolis
Mladen Djurasovic, MD, clinical assistant professor, department of orthopedic surgery at the University of Louisville and spine surgeon, Norton Leatherman Spine Center, Louisville, Ky.
Keith Kenter, MD, associate professor of orthopedic surgery and director of the orthopedic surgery residency program at the University of Cincinnati
William Levine, MD, professor of clinical orthopedic surgery, vice chairman of education in the department of orthopedic surgery, director of the sports medicine department of orthopedic surgery, associate director of the Center for Shoulder, Elbow and sports medicine and residency program director of orthopedic surgery, Columbia University Medical Center in New York City
Bradford O. Parsons, MD, assistant professor of orthopedics, Mount Sinai School of Medicine, New York City.
K. Daniel Riew, MD, Mildred B. Simon Distinguished Professor of Orthopedic Surgery, Professor of Neurological Surgery, Chief, Cervical Spine Surgery, Washington University Orthopedics, Washington University School of Medicine, St. Louis
Robert Sterling, MD, associate professor of orthopedics and residency program director in the department of orthopedics, University of Maryland School of Medicine, Baltimore
Paul Tonetta, III, MD, professor and vice chairman of the department of orthopedic surgery and director of the orthopedic residency training program, Boston University School of Medicine, director of orthopedic trauma, Boston Medical Center.
More Articles on Orthopedic Surgery:
10 Spine Surgeons on Factors of Spinal Fusion's 137% Jump in 10 Years
6 Steps to Prepare for the Future of Outpatient Spine Surgery
4 Tips for the Entrepreneurial Business-Minded Spine Surgeon