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Develop a clear vision of what is most important for personal satisfaction, happiness
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Finding a job as an orthopedic surgeon is not difficult. Many factors play a role in the available opportunities, including areas with physician shortages, subspecialization and changes in health care delivery. However, finding the ideal job has become increasingly difficult. In many major metropolitan areas, the uncertainty of future health care delivery models and partnerships has led to a conservative approach for adding new partners.
Many private practice groups, solo practitioners and academic-based programs do not have ultimate control over patient referrals and access to large groups of patients. Adding a new surgeon is often perceived as an expense which divides the existing pool of patients. Until a new surgeon can increase the referrals, he or she is additional overhead with a minor increase in the top-line revenue, thereby reducing net profits to the practice. Also, orthopedic surgeons are known to be “territorial,” so the addition of new partners with a perceived similar skill set are not easily accepted. Practices tend to focus on areas of perceived deficiency in the offered services or areas with existing high patient volumes.
Anthony A. Romeo
Factors for residents
At this time of the academic year, many young colleagues are preoccupied with identifying what they want life to be for the next 5 years to 10 years. More than 90% of graduating residents will complete a 1-year fellowship and up to 10% will complete a second fellowship before entering the job market. Applications are completed, letters of recommendation are sent and interviews begin. By the time residents have completed their third year of residency, 77% have selected a subspecialty, so they have been contemplating the process that leads to their first job for years before it actually happens.
While many cynical observers believe the decision is based on financial considerations, numerous studies have demonstrated this is the least important factor at this time in their careers. Residents choose fellowships primarily based on the intellectual stimulation they experience during subspecialty rotation, mentorship, perceived lifestyle and the compatibility of their personality with others in that field. They have a sense of where they would like to be after fellowship. Considerations such as job marketability and opportunity to develop a niche in an underserved subspecialty also play a greater role in the decision-making process.
The average resident now leaves training with $150,000 or more of debt. Added to their financial stress is an additional year, often in a new location, and then the expense of moving 1 year later. Once in practice, young colleagues will experience declining revenues for the amount of work provided. During the last 10 years, revenue when adjusted for inflation, has been affected with net income per patient visit for professional services decreasing by 64%. Senior partners have worked hard to develop ancillary services to cover lost revenue, however, typically these resources are not considered for new partners. Net income from professional plus ancillary services adjusted for inflation during the past decade also has decreased 41%.
In mind, in reality
With these obstacles in mind, the most valuable knowledge a prospective job applicant can develop is a clear vision of what is most important for personal satisfaction and happiness. Most things in life are created twice — once in one’s mind and then in reality. After completing 5 years of residency, fellowship or a few years in practice, appropriate introspection helps reveal the subspecialty one is passionate about. It is critical to understand that responsibilities are associated with happiness and personal satisfaction. Professional factors include the ideal working environment for surgical cases, availability to operate or practice in the office, ability to identify and hire support staff, and educational desires. On a personal level, there should be an effort to understand a spouse’s or partner’s personal vision of the future, children’s needs, housing options and proximity to family.
The skill set of searching for a job is roughly developed during the final years of training and early practice. It should not be discarded since physician turnover rates in the second to third year of practice is 12% and can be more than 20% in smaller groups. Often the most significant constraint due to family or personal reasons is the desire to live in a specific geographic region.
Contact leaders
Depending on the type of practice desired, surgeons in leadership positions should be contacted in the desired area 1 year to 2 years in advance to explore and possibly create opportunities. Job advertisements can be found in major orthopedic publications and online, however, many jobs that come to fruition are not advertised or even developed at the time of inquiry. However, the right timing, person and subspecialty training can set in motion a process of establishing a unique opportunity.
The effort to work with leaders is critical, even if the timing does not work out when the applicant is ready for employment. With high turnover rates after a few years of practice, it is important to build bridges and keep all options open as long as possible.
Understand priorities
Once applicants identify a potential job, it becomes even more critical that they understand their priorities. No offer is perfect and compromise is essential. It is valuable to develop a list of job characteristics which are broken down into as essential, desirable but not critical, and unacceptable. The more flexible one is, the more impact personal skills, availability and affability have to create an ideal situation. However, early career positions are often not flexible with very specific parameters as set by the practice, hospital or surgicenter.
Job applicants need to identify subtle but critical factors, including available operating room time, office scheduling, ability to add-on cases, call schedule, operating room and clinical equipment allowance and availability, and support staff. One skill set not readily developed during training is the ability to properly select staff who will surround you and often are a positive or negative difference in every day professional life.
The penalties, compensation
The most important aspect of the financial compensation package is not the salary and benefits, but the penalties of walking away from the job. While no one wants to accept a job thinking they will leave soon, many orthopedic surgeons decide within a few years that another opportunity is better for them. However, the practice has a vested interest in maintaining the employment or partnership, so certain penalties are built into contracts to minimize risks and potential losses when someone leaves. The applicant must analyze the opportunity from the severity of the penalties for leaving. The penalties can include malpractice tail insurance, restrictive covenants in terms of geographic constraints of relocating a practice, high buy-in costs to the partnership not realized until becoming a partner, and the “ill will” that may affect future academic or private practice opportunities.
Once these issues are understood and accepted, the last issue discussed is the method and amount of compensation. Compensation can be a performance-based model, salary-based model or a hybrid of the two concepts. Ideally, there is a reasonable base compensation or salary, and then the opportunity to reward performance with a modest bonus plan. Furthermore, there is a clear definition of future compensation adjustments based on tenure or partnership, performance and other factors, such as academic accomplishments or practice leadership. There are a variety of resources, including peers, recent additions to the practice and published data to provide context to the myriad of compensation packages available.
Embrace the opportunity
Once the decision has been made, accept and embrace the job opportunity. Plan for success by giving 100% to the position and using all acquired skills. Be humble, available and affable to everyone in the organization. Have a plan for continued education and surgical skill improvement as new hires are at the infancy of what can be achieved with time and effort. Understand it may not be the final job, but act like it is. The ability to identify and acquire a better situation will be heavily predicated on the successes achieved in this job opportunity.
Finally, starting a new job is the best time to reassess one’s commitment to personal and the family’s health and happiness. While many in orthopedic surgeons are likely to spend more awake hours at work than at home, remember the ability to achieve the greatest success in life is truly based on the quality and sincerity of effort at home.
For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.