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“10 Things Your Mom Forgot to Tell You About the Real World” — Private Practice

Thursday, January 12, 2012

10. Check your ego at the door.

Cardiothoracic surgery is one of the most competitive fields in medicine. Unlike some other fields of medicine where a shingle and an open door will lead to patients, we are 100% reliant on referrals. To succeed, you will have to be Available, Affable, and Able—and in that order. Motivating cardiologists to send you cases when you are a green, newbie CT surgeon is difficult—especially when they have alternatives that they know, trust, like and with whom they have had long, successful relationships. Know that one bad interaction with a cardiologist could mean that you may never see another referral again from that doctor.

In Henry IV Falstaff says this—“The better part of valour is discretion; in which the better part of I have saved my life.” What he means is that you can be brave, but be thoughtful about what battles you choose to fight. You want to stay alive in your young professional life. There is no honor in going down in flames by trying to take on high risk cases in your first few months. While you will have many years to take on the tough cases you will only have one shot at a first impression. Show the cardiologists that you are thoughtful and want what is best for the patients—even if it means saying you will not operate.

Plan to spend the first three years of your post graduate life being on call 24/7. I'm not saying don't take any vacations—but don't take many. Make it clear that you are ALWAYS available. Drift by the cath lab. Make your presence known. Try to build real friendships with your referring doctors. Building a practice is hard work and no matter how good you are if you aren’t there and if you aren’t nice you will not be able to put food on your family’s table.

9. Swallow your pride (yes it does sound like #10 but the subject is different)

If you are given the opportunity to have someone hold your hand and be there scrubbing cases with you for the first 3 to 6 months then by all means EMBRACE it. You have the next 30 years to operate by yourself. Some senior surgeons will only come if asked. Well, ask them! In fact, ask them before you take the job. Beware of jobs where surgeons are so busy and RVU or profit driven that you can imagine it would be hard to take time out from their busy schedule to help you out. You want them there for a number of reasons. First, they can teach you things and provide a different perspective in approaching the operation. Ask them to look at the cardiac catheterization reports with you. The last thing you want to do is come into town like you are the second coming of Denton Cooley and disrespect the old guard. You will not last. And moreover, when you get into trouble they will be there to help you. And, not if but when you have a bad outcome you better believe that whoever the referring doctor was will want to know if you were alone or with someone else. If you were alone, you can pretty much guarantee that that guy, and perhaps his partners as well, will not be sending you any more patients.

A finer point here on catheterizations and catheterization reports

Make sure you read the catheterization reports carefully. Early on I reviewed the reports with the cardiologists to be clear on what they thought needed grafting and what I thought. This does a few things. First it shows them that you are detail oriented and on top of things. Secondly it gives you some more contact time with them so they start to know you and—it also makes you sure that you are going in to do the right thing.

Some cardiologists will actually specify what they think needs grafting in the report. If there is a small vessel that they say should be grafted you need to talk with them Before the case to tell them that “I will take a look at that one Bob but it looks small and I'm not sure I can get a graft into there.” This way when they see the vessel not grafted, it will not be a surprise and they will not think you failed to fully revascularize the patient. This type of interaction is important for cardiologist/surgeon relations.

8. Don't focus on your first paycheck.

When I finished my training, I was exhausted, broke, and in lots of debt. I was very focused on the amount of money that I was going to make coming out. Some jobs paid twice that of another. These salaries colored my thinking but I didn't realize at the time that the salaries didn't mean much. You will have many factors telling you otherwise including your significant other but stick to your guns and find the job that will allow you to be successful in becoming a cardiothoracic surgeon.

Getting good at heart surgery (or anything for that matter) is about repetition. You have got to get the reps and if the reps are not there then it is not a good first job. Scrubbing cases with your partners does not count. The only cases that count are the ones you are doing on your own, with Your name on the chart, with no partner in the room so you can get comfortable and learn how to get out of trouble and make some of the tough decisions we have to make.

To be clear – if you have to choose between money or the chance to operate do NOT choose the money. You will eat what you kill very soon – your first salary that is not production based will only last for a year or two.

7. Do not buy a big house. Or any house in the first year for that matter.

A significant number people in this business do not keep their first job. This is because it is VERY hard to find a good first job. The nature of this heart surgery is that it is hard to find a good first job that will allow you to truly build a practice and stay. Most heart surgeons who have worked very hard to build a practice will not be willing to just “give” you cases from these cardiologists whose trust and respect they have worked many years to earn. True private practice groups will make money from your cases but these jobs are now few and far between—it is more likely that you will be a hospital employee. In that case you may be in a group bonus structure which still might increase incentive for your “partners” to give you cases but usually they are trying to hit their own production targets and will be tight-fisted about giving cases away.

On this note, do not begrudge your partners for not giving you cases. They have spent many hard fought years building their practices, sweating out hundreds of tough cases, working to bolster relationships with the referring doctors and they understandably do not want to do anything to jeopardize that.

In many cases a young guy is hired to help take call, but not necessarily take a bulk of the cases away from the senior partners. If you rent then it will take a lot of stress away from you and your wife if are not SURE that this job is going to work out for you. And as far as I am concerned nothing is a sure thing unless you have been somewhere about 3 years and things look like they are going to continue to go well for you. You will be throwing some money down the tube but in my opinion that is better than carrying two mortgages or a lease and a mortgage when you have to leave town.

6. Sweat during peacetime so you don’t bleed during war.

Whether or not they really say this it is still very apt when it comes to the training of a heart surgeon. I know what it feels like to feel like your training is interminable. Like Bill Murray stuck in some horrible medical version of Groundhog day, you feel like you will never get to the end. Trust me It will end. With that in mind do as many cases as you can during your training, put yourself in as many uncomfortable situations that you can. The Future You will thank the Residency You. In your last 6 months of training you should be allowed to do most of the cases alone. Ask the surgeons who are training you if they need to scrub then can they second assist. Do your cases with first year medical students. The more you can simulate what it’s going to be like to be out in the real world with no net, no umbilical cord, the better.

No matter what you think there is no substitute to standing there alone without someone to tell you—verbally or non-verbally—were to put the stitches. What you don’t even realize is that often you will have someone who will say, “no” if you are putting a stitch in the wrong place. It takes a very long time to program yourself to not operate in that manner where you are constantly being watched, helped, and guided. So try to spend as much time in your training without an attending in the room—because that is the ONLY way you gain real confidence.

5. If momma ain’t happy, nobody is happy.

Some of you are married, or will be married. Factor in your spouses feelings about where you will work. You will be gone a lot – so if there is a place where there are already family or friends, this will be a bonus. Your spouse will have already gone through a very stressful time helping you get through your training. They have thought that when training finishes that there will be a pot of gold at the end of the rainbow. What they don’t realize is that things really don’t get a whole lot easier, the stress will actually rise, however you will be able to finally start paying off your debt.

Do not take your spouse for granted. There is a reason why heart surgeons have one of the highest divorce rates in medicine. One is that many surgeons spend a lot of time in the hospital, have narcissistic personalities and decide that the rules of normal behavior don't apply to them. All I can say is do your best to make sure you don't end up a statistic. I was once told by Dr. John Tarpley, an amazing surgeon who has spent most of his adult life doing missionary work when he is not the program director for general surgery at Vanderbilt to, “Always be courting your wife.” Your spouse isn't looking for much but always try to be thoughtful of them. Take them to dinner once a week. Bring them flowers. Do not let your marriage wither on the vine.

Side Note:

Obviously my advice may seem like I'm speaking out of both sides of my mouth. What if there is a job in your spouse's home town that she desperately wants you to take but it looks like all you will be doing it taking call, and have no real prospects of being able to operate on your own? And there is a job in Podunk, East Nowhere that will allow you to operate like crazy and get your skills?

Answer: Hopefully your marriage is strong enough to stand a few years in Podunk—because in my opinion that is where you should go. You need to explain to your spouse that the job in the hometown is a dead end and is not what is best for you, your future, and the family's future in the end.

4. Get some extra training if you can stand it.

I wrote an essay a few years ago in which I was asked to debate a two-year versus a three-year program. I was pretty cooked after 9 years of post medical school training and could not conceive of additional years of training. While much of that essay was tongue and cheek I did feel at that time that if you can do the same thing in two years that you could in three then what is the point? Now—there are some three year programs that are more like a two year program with a somewhat “elective” third year. I think that in today’s market spending another year getting good at endovascular techniques, perhaps complex coronary work, or even spending a year doing TAVI training would be good for job hunting, but also would potentially give you an edge in a competitive market. This also goes for those of you who are going into non-cardiac thoracic. Spending some time learning to do minimally invasive esophagectomies, VATS lobes and other VATS interventions will make you a very eligible applicant and will put you ahead of the game.

3. Are you replacing or building?

This is probably one of the most important things for you to understand coming in. Are you replacing a surgeon who will be retiring? Or have you been told that “business is thriving” and they “need another surgeon”. If they tell you that then ask them to show you the data—are cases really growing? I will tell you that the first is good (replacement), the second (“business is booming”) you have to really examine closely. In the case of replacing another surgeon you can feel pretty good about the fact that there will be VOLUME there for you. In most places, the number of hearts is set from year to year- roughly. You will start to learn that this place does 300 hearts while that place does 500… and those numbers will seem irrelevant at first. What you need to know is they are VERY relevant, because it will tell you whether or not you are going to fly or not.


I saw this special on the National Geographic channel where little birds would hatch and jump from a cliff about 800 feet down into the water. (YouTube Video) This is their first time ever flying! Their parents fly behind them in this terrifying, death defying act which is also Darwinian natural selection working in its cruelest, most efficient manner. I found these little Guillemot chicks and their terrifying leap to the ocean to be the perfect metaphor for what it is like starting out as a young heart surgeon.

You have one shot to get it right coming out. So if you can find a situation where you are actually replacing a surgeon in a practice and the partners seem like reasonable guys who will not split his volume up and only use you for call then you have a pretty good situation. AGAIN DON’T WORRY ABOUT WHAT THEY ARE GOING TO PAY YOU. At least the first two years.

The reason a private practice will pay you so little is that they will be paying you out of pocket versus a hospital that can pay you a very good salary at first. However that hospital will not give you that good salary indefinitely. In a year or two you will have to earn that salary—or more.

Generally you want at least 100 pump cases that will be yours, a year, for the first two years. If the job cannot show you that you have a very good chance at that many cases or more, then you should smell a bit of a rat and try to find somewhere else that you can take off from that cliff and have a chance to make it to the water.

2. Be patient and try to picture yourself living in a Zen Bubble.

It will take a few years to get your legs under you. One of the surgeons with whom I interviewed for a job told me he didn’t feel comfortable in the operating room until his third year out from training. You will be under a huge amount of stress in your first few months coming out. There are few jobs like this where not only does your patients life depend on you but your life depends on you too. Failure has huge consequences for the patient but also you, your family, your life. It is hard not to be thinking of all of these stressful things when you are first starting out.

You will have an enormous amount of stress. There are ways to deal with this. Read about Zen Buddhism, take up yoga, read what the Stoics had to say (The Meditations of Marcus Aurelius should be sitting on your desk at work). Read Olser’s address, “Aequinimitas”. These are techniques (try to count your breathing—deep and slow—and still be stressed out) and philosophical approaches to the stressors of life that have been present and very effective for HUNDREDS of years.

You will be uncomfortable. There is no way around it. But try to be calm and dignified in those moments of discomfort. For some of you this will come easier than others:

As Olser said in his address, "As imperturbability is largely a bodily endowment, I regret to say that there are those amongst you, who, owing to congenital defects, may never be able to acquire it. Education, however, will do much; and with practice and experience the majority of you may expect to attain to a fair measure."

1. Don’t forget to enjoy yourself.

Do whatever it takes in the operating room to enjoy what you are doing, because you are one of the lucky ones. Play the music you like to get your mind in the right frame. You get to do something so amazing, so challenging, and so satisfying with your life. It can be very hard to not focus on every mammary takedown, every cannulation, every anastomosis as not only being life and death for the patient but life and death for you, your family, your reputation. The fact of the matter is that all of those fears are true. You must find a way to whistle past the graveyard, know that no matter what things usually work out…



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