Transitioning From Fellowship to Practice
What every vascular surgery resident or fellow needs to know.
Currently in the United States, a fellowship integrated residency is required to become board eligible in the field of vascular surgery. During their training, physicians learn vascular anatomy, physiology, and pathophysiology. They are taught the differential diagnosis, work up, and medical management of vascular disease, and they learn about cross-sectional imaging and the noninvasive vascular laboratory. Finally, trainees acquire and hone open surgical and endovascular techniques that will enable them to treat patients with peripheral vascular disease.1 Few would disagree that training to become a vascular surgeon is an intense, rich experience and that at the end of their apprenticeship trainees are able to independently manage patients with vascular disease.
However, there is more to being a vascular surgeon than performing a vascular anastomosis. Real world practice demands exposure to a variety of other skills that have traditionally not occupied a significant role in vascular training curricula. Learning how to craft a curriculum vitae (CV), how to look for a job, how to interact with a prospective employer, how to interview, how to assess an employment opportunity, and how to negotiate a contract are not routinely taught to vascular trainees. Furthermore, few trainees are formally educated about the different practice environments that vascular surgeons work in, different ways that they earn an income, and the range of that income potential. Finally, there is little emphasis placed on preparing the trainee for their first year in practice; details of vascular coding, interaction strategies with partners, referring physicians, and interventionist colleagues, and strategies of how to succeed in a given environment are all left to the trainee to figure out once they start their job. There has been reluctance to teach these skills in the medical profession. Conversely, skills that are imperative for success in the workplace are routinely taught in business school. Given the changes that are affecting our health care system, it is now more important than ever for vascular trainees to enter the workplace prepared to negotiate the complexities integrated residency is required to become board eligible in the field of vascular surgery. During their training, physicians learn vascular meetings.
BEGINNING THE JOB SEARCH
Due to high demands of their training programs, residents and fellows in vascular surgery seldom devote a significant amount of time thinking about what type of environment they want to ultimately practice in. This soul searching, however, is invaluable in organizing the successful job search process. Before starting the job search, the trainee should take time away from the stresses of clinical practice to reflect on what is important to him or her and to consider the following questions.
How do I want to spend my day?
The practice of vascular surgery can be broken down into a number of components: clinical practice, research, teaching, and administration. Clinical practice includes evaluation of patients in the office and hospital, open vascular surgery, and endovascular therapy. Research can be basic science, translational, or clinical. Teaching involves didactic and bedside education of students, residents, or fellows. Administration entails management of an office, a training program, a department, or a hospital. Each potential job, irrespective of practice type, includes some or all of these components in various ratios to one another. There is no question that engagement in activities that are enjoyable to the surgeon will lead to a happy work experience. The opposite will contribute to work dissatisfaction. It is therefore essential for the trainee to consider which of these components of practice are both important and palatable. For instance, if the trainee does not like teaching then it may be unwise to accept a job in academics. Likewise, if the trainee enjoys the thrill of presenting at meetings, it would be optimal to search for a job where this activity is possible.
What sort of environment do I want to practice in?
In the past, private and academic practices were the main work settings available to the graduating vascular surgeon. Recently, the distinction between these environments has become blurred. Other practice options are available, and it is not altogether clear what the future of medicine will hold. In traditional private practice the surgeon ran a business whose product was clinical care of the vascular surgery patient. Activities that did not generate revenue, such as teaching and research, were not deemed important. Conversely, in academic practice, the surgeon held an appointment at a medical school, was part of a faculty practice plan, was expected to teach trainees, and participated in research. Decreasing reimbursements, increasing malpractice costs, increasing office expenses, and increasing regulatory bureaucracy affected both models of practice. These factors have made solo practice in vascular surgery difficult. In fact, there has been a significant decrease in the number of independent physicians practicing surgery in the United States.2 Physicians have adapted by joining single or multispecialty groups, engaging in revenue generating activities other than clinical vascular surgery, and leaving private practice. Many vascular surgeons have sold their practices and opted to work as employees of a hospital, multispecialty group, or health maintenance organization. In academics, some groups were compelled to reevaluate the importance of research and teaching as nonrevenue-generating practices. The trainee looking for a job in 2010 should be aware of the dynamic changes to the practice environment of vascular surgery and avoid the temptation of looking at job opportunities through the prism of what private and academic practice was like 10 years ago.
What are my ultimate career goals?
Although career paths commonly change, it is important for trainees to strategize on what they are looking for in their vascular surgery job and where they want to find themselves 10 years later. For instance, if the trainee desires a job that does not involve significant on-call time, he or she may wish to join an established vein center. Alternatively, if the trainee wants to eventually become a department chief, he or she needs to accept the long hours, research, and administrative efforts that will need to be applied to achieve that goal.
How important is the geographical location of my job?
The job pathway can be defined as a series of steps that an applicant needs to take before deciding on a position. This series of events can be broken down into several components: identification of job opportunities, initial contact with a prospective employer, interview, evaluation of offer, and negotiation of terms.
To be successful in obtaining a desirable job, it is important for the trainee to be aware of the subtleties involved in this process. Unfortunately, the “devil is in the details,” and those who are unaware of these details are apt to make critical mistakes that will either cause them to lose a desired position or to accept a job that will be ultimately be unsatisfying.
Identification of Job Opportunities
There are currently a number of ways that employment opportunities can be identified. These include the classified ads in the Journal of Vascular Surgery and a robust job listing on the Society for Vascular Surgery Web site (www.vascularweb.org). Division chiefs and program directors are frequently contacted by prospective employers and, therefore, can be an invaluable asset in this process. There a number of recruiting firms that specialize in placing vascular surgeons. Finally, because many desirable positions are not posted, local or regional vascular meetings may present a good opportunity to inter- act with prospective employers.
Initial Contact With a Prospective Employer
Typically, the trainee will contact the prospective employer by forwarding a short letter of interest and a CV. The CV should be written in easily legible font and organized in a logical, symmetrical fashion. It must be accurate, proofread, and spellchecked. Mistakes on a CV, no matter how small, will be interpreted as representative of the applicant’s work product and will be looked at askance by the prospective employer. It is useful for the trainee to look at the CV of his or her mentor or chief and model it appropriately.
After receiving and reviewing the applicant’s CV, the prospective employer will usually contact the trainee by telephone. This first contact is important because first impressions matter. The trainee needs to understand that the goal of the first conversation is to be invited for an inter- view. He or she should appear genuinely interested, spend more time listening than talking, not appear overly confident, and always have questions to ask about the position.
The interview process is an important component of the job pathway. It is an opportunity for the applicant to learn about the practice and the prospective employer to learn about the applicant. Poor performance during an interview will rarely lead to a job offer. During the interview, which will typically involve a visit to the practice, the applicant will meet with the prospective employer and colleagues, office staff, affiliated specialists, and representatives of hospital administration. The applicant will tour the facilities and have dinner with the surgeons. With regard to the first inter- view the applicant has two main objectives. The first objec- tive is to gather information about the practice and the sec- ond objective is to be liked. It is imperative for the applicant to make a concerted effort during this visit to understand the positive and negative aspects of the practice. At the same time, he or she needs to behave in a way that would lead the prospective employer to extend an invitation for a second interview and eventually an offer.
The interview begins the minute that the applicant meets with the prospective employer. This may occur at the airport, a time and place that is sooner than the applicant may anticipate. Because first impressions are important, it behooves the applicant to be appropriately dressed and prepared for such an occasion. The applicant should always act interested, never be argumentative, confrontational, or condescending. He or she should be courteous to everyone; people that are perceived as not being important may have an unanticipated role in the interview process. Money or vacation time should not be brought up by the trainee applicant during the course of the first interview.
A successful first interview will often lead to an invitation for a second interview. The applicant will typically be invited back with his or her significant other. He or she will, once again, meet with everyone, have dinner with surgeons and their spouses, and have a real estate tour. The purpose of the second interview, from the perspective of the employer, is threefold: to take a second look at the applicant, to entice the applicant to accept a forthcoming offer, and to entice the applicant’s significant other. In preparation, the applicant must be acutely aware of what he or she “brings to the table” and how this can contribute to the success of the practice. The applicant should try to meet with everyone of importance. For instance, an applicant who is interested in developing a dialysis access practice should meet with area nephrologists. The goal of the second interview, for the trainee, is to critically evaluate the opportunity, to critically evaluate the community, and to gather enough information to make the right decision should a job offer be extended.
Evaluating the Offer
The job offer is typically extended during or after the second interview. Before accepting a job, it is crucial to critically compare the offer with other pending job opportunities. To that end, the applicant needs to answer a number of important questions.
Why are they looking for someone? There are multiple reasons why a surgeon or group of surgeons may be interested in adding another associate. It behooves the applicant to understand those reasons. From the applicant’s perspective, the following are positive reasons: expansion to another hospital with associated increase in case volume or market share and the need for specific expertise possessed by the applicant. Negative reasons include need for on-call coverage and operating room assistance. Applicants should avoid job opportunities where the reasons for a surgeon search are unclear. Such opportunities rarely lead to success and job satisfaction.
A common reason for a group to hire is to replace a surgeon who left the practice. Although there is always a rehearsed explanation for such a departure the applicant should make every effort to find out the real reason. Getting in touch with that individual may be the best way to not only get that question answered but also to learn invaluable information about the practice.
Can I work with this group? When evaluating an opportunity, attention needs to be focused on the interaction between surgeons within the group. Although, it is impossible to fully appreciate such intricacies from one or two visits, much can be learned even during limited exposure. A tension-filled environment where the surgeons do not appear happy or do not get along will rarely provide for a good professional opportunity.
Is a senior vascular surgeon available for advice and help with cases? Most physicians upon completion of their training are prepared to start clinical practice. However, a significant amount of learning has yet to occur for the trainee to mature into a capable vascular surgeon. This learning occurs best in an environment where experienced vascular surgeons are willing and able to assist in patient management in and out of the operating room. It behooves the freshly trained vascular surgeon to avoid a job environment where there is a lack of senior vascular surgery back up.
What is the status of endovascular access? Endovascular therapy has become an integral part of the modern vascular surgeon’s armamentarium. Despite this fact, there are still institutions where turf wars among interventionists over endovascular privileges and access are in progress. The applicant needs to understand the details of endovascular credentialing and the environment of each job opportunity. The optimal environment is such where the appropriately trained applicant will have full privileges to freely schedule and perform endovascular procedures in a top of the line endovascular suite. The applicant needs to be wary of an environment where he or she will have limited endovascular privileges, have restricted access to an endovascular suite, or have access to a rudimentary endovascular setting such as a C-arm in the operating room in an institution that has well-equipped endovascular suites. Lastly, the applicant should beware of scenarios in which the hiring group has ingrained referral patterns of endovascular cases to other interventionists.
Will it be possible for me to succeed?Although every graduating vascular surgeon wants to succeed in his or her new job, such success is far from assured. It is imperative for the applicant to critically evaluate factors that will be important for such success. It is likewise important to understand how the employer will measure success. The are several potential metrics: charges, collections, relative value units, manuscripts published, grants submitted, and ability to fit in and get along with others. The applicant has to clearly understand which of these metrics will be used to evaluate him or her. Success can be rewarded by partnership, academic promotion, and money. It goes without saying that it is important to understand how the employer will reward success.
In many modern practices, endovascular therapy constitutes a significant and growing proportion of case volume. Therefore, it is imperative for the job opportunity to allow for full endovascular privileges, an appropriate endovascular environment to practice, and opportunity to have referrals for such procedures. It is hard to succeed if impediments to developing a busy endovascular practice exist.
The applicant needs to understand the agenda of the employer as it relates to him or her. The assumption that the hiring surgeon is interested in the applicant’s personal success may not be accurate. Other factors may be operational. Success will be much more likely if the agenda of the applicant is parallel to the agenda of the employer.
A vascular surgeon in clinical practice typically competes with other surgeons and physicians. As part of this competition each party has advantages and disadvantages. The applicant needs to understand both the identity and strengths of these parties. The applicant must beware of scenarios where he or she will be directly competing with future partners or associates; such work environment rarely leads to success and job satisfaction.
Finally, an important fact to consider is whether the applicant will be able to share equally in the financial success of the practice. An assumption that this is true may be inaccurate. It is important to understand how the hiring group earns an income, what the sources of such income are, and whether certain individuals have exclusive rights to specific income streams.
Negotiation of Terms
Upon extension of an offer most employers will send the applicant a contract. Such contracts are crafted to leverage and optimize employer terms. It is best to have the contract reviewed by an attorney who specializes in medical contracts. Terms of negotiation can potentially include starting salary, potential future income and its sources, length of partnership track, vacation, benefits, presence of restrictive covenants, malpractice insurance tail coverage, and termination. Before engaging in negotiation, the trainee needs to assess what value he or she brings to the practice. Unfortunately, many trainees may either not appreciate their value or, by the virtue of their inexperience, have limited value. This may curb the negotiating power that the trainee possesses for “big ticket” items such as length of partnership track or potential future income and its sources.
The starting salary is typically negotiable; vacation and benefits are usually not. Of utmost importance is to negotiate the malpractice tail coverage for claims-made policies. Such tail coverage should be partially or fully paid by the employer on the occasion of termination because its monetary value may be very high. The applicant should avoid signing a contract that allows for termination with- out cause. If the group resists removing this clause, it needs to be buttressed by a requirement for warnings and fees levied on the group in the case of involuntary termination.
EARNING AN INCOME
Few residents or fellows are aware of the various ways that vascular surgeons earn an income and what the range of income is in private and academic settings. It is important for the trainee to be familiar with this information as he or she enters the workforce so that appropriate expectations can be set.
Traditionally, open vascular and endovascular procedures, management of a vascular laboratory, and reading of noninvasive vascular studies comprised the “bread and butter”ofvascularsurgeryincome.Decreasingprocedural reimbursements have forced many vascular surgeons to earn an income in less traditional ways. The following is a partial list of income stream components of many of today’s vascular surgeons:
- Assisting spine surgeons with anterior exposure of the spine,
- Developing a cosmetic vein practice,
- Receiving salary from a hospital for services such asdirecting a wound center, operating rooms, vascular center, etc.,
- Engaging in industry-sponsored clinical trials,
- Maintaining ownership shares in a dialysis access center or surgery center,
- Consulting for industry,
- Legal expert review.
During potential job opportunity evaluation, the trainee needs to inquire about whether the hiring surgeons participate in these income-generating activities. It is important to clarify whether the applicant will be allowed to either engage in these activities or have an opportunity to share in this income stream.
Professional income is rarely formally discussed in vascular training programs. Yet, it is critically important for vascular trainees to know what mean incomes can be generated by a vascular surgeon. This knowledge is important for both contract negotiation and setting of appropriate expectations for life planning. Table 1 lists recently published vascular surgery annual compensation statistics based on type and region of practice.3 These values were derived from a formalized survey that included physicians in both academic and private practice settings. Table 2 specifically summarizes statistics on vascular surgery annual salaries in an academic setting.4
For the vascular surgery trainee, transitioning from fellowship to practice represents the culmination of many years of learning, hard work, and sacrifice. Despite extensive training necessary to become a vascular surgeon, few trainees are prepared for the vagaries of the job search and the complexities of the first years of practice. In order to develop skills necessary for success, individual trainees need to actively pursue learning the particulars of realworld practice. Conversely, leadership of the vascular surgery community needs to ensure that this information is formally disseminated during fellowship training.
Alik Farber, MD, is Chief of Vascular and Endovascular Surgery, Boston Medical Center, and Associate Professor of Surgery and Radiology, Boston University School of Medicine in Boston, Massachusetts. Dr. Farber may be reached at firstname.lastname@example.org.
- Accreditation Council for Graduate Medical Education. Surgery Program requirements. Available at www.acgme.org/acWebsite/RRC_440/440_prIndex.asp. Accessed September 23, 2009.
- Isaacs S, Jellinek PS, Ray WL. The independent physician—going, going... N Engl J Med. 2009;360:655-657.
- Physician Compensation and Production Survey: 2009 Report Based on 2008 Data. MGMA. 2009:246. 4. Report on Medical School Faculty Salaries: 2007-2008. Summary Statistics on Medical School Faculty Compensation for All Schools MD or Equivalent Degree, Clinical Science Departments/Specialties Total Compensation in Thousands of Dollars. AAMC. 2009:43.