Vascular fellows entering the job market should take a moment to reflect and create a personalized recipe for how to land the ideal and best-fit job. With the current economic climate and dwindling reimbursement, many large academic and private practices are reluctant to guarantee big startup salaries and support time for research. I do not wish to paint a gloomy picture of the postgraduate world but would urge fellows to be realistic as well as cautiously optimistic before making career decisions. In this article, I will share a few of the blunders I made when I first started and how to correct them to help you avoid making similar mistakes while continuing to grow professionally and personally.

YOU AIN'T NO DEBAKEY . . .  AT LEAST NOT FOR THE FIRST YEAR

Remember that no matter how well trained you are, you still lack real-world experience and have an uphill road to prove your competence as a vascular surgeon. Plan straightforward cases for at least your first 3 months to establish a good reputation among nurses and staff. Asking for help in the operating room is not easy, but it will help you to develop good relationships as well as good outcomes. Do not approach cases with the same cavalier fashion as you might have done as a fellow. Discuss complex cases (including straightforward endovascular aneurysm repair) with at least one of your partners and be prepared to ask for assistance in the operating room even though you might think that you are too good to do so.

DO NOT UPSET THE CHIEF

I think this was my biggest mistake when I began my career. I was completely out of sync with the entire division and, most importantly, my boss. The worst part was that I did not even see it. I was trying too hard to impress myself with what I could do as a member of the faculty. I realized that my plans and achievements were minimal when I finally looked at the big picture; my boss was trying to make me see things in a more diplomatic way. My recommendation is to understand what you were hired to do and play that role well. Your boss has the ability and connections to help you realize your professional plans and dreams, so be smart and do not step on your boss's toes.

RECOGNIZE WHAT YOU ARE GOOD AT— NOT WHAT YOU THINK YOU ARE GOOD AT

If writing papers or doing research is not your forte, then do not enter academia. If you want to make millions and retire at 40, then you should not have entered this business from the start. Recognize what you are good at and exploit it. Your strong suit may be having good technical skills (rarely the case for new graduates), the ability to write well, obtaining extramural funding, or having a charming personality (can happen occasionally).

DON'T SEND CRAZY EMAILS

When Lincoln lost a battle, he wrote a letter to his general to reprimand him for not following orders. He never sent that letter and lived to win the war. Now that you are the attending, you may think that the world revolves around you. Of course this is a myth, and you better debunk it before starting your job. Your hospital administrator does not care if you do complex cases or trained in the best places. Do not get caught in the moment and send an inappropriate email to the chief of nursing or a hospital executive just because he or she did not provide what you needed in a timely fashion. This will get you nowhere and certainly will backfire on you within your division and department. Building a good relationship with your staff and administration is not only helpful in the dayto- day running of affairs but can also be very handy when you want to introduce new technology and increase your patient outreach.

LIKE YOUR PARENTS, YOU DON'T CHOOSE YOUR PARTNERS

Remember that your employer hired you—not the other way around. You cannot give your employer an attitude when you are considered a guest, particularly during your first year. It is important to treat each relationship with care, making yourself available, asking if you can be of assistance, showing up when you are least expected, taking calls, respecting privacy, and sharing accomplishments. Do not boast, and accommodate others as much as you can. You are disposable until you earn the respect of your partners.

ASK WHAT YOU CAN DO FOR YOUR GROUP, NOT WHAT YOUR GROUP CAN DO FOR YOU

Try to add a new dimension to your group. If your group needs someone to do certain cases, volunteer to take them on; if any of your partners are overwhelmed with mundane paperwork and institutional obligations, offer to help. A big mistake is to think that you are busier than others and that you don't have time for additional tasks. Your attitude should be, “Bring it on. I can do it.”

ROME WAS NOT BUILT IN A DAY AND NEITHER WAS THE REFERRAL

The issue of referrals may not come into play immediately, but it absolutely will be an issue down the line. I never had a business-oriented view of medicine, and frankly, I ignored my development in this category. After a while, it became necessary and impossible to ignore; however, I must admit, it is now fun and adds a great deal of satisfaction to my job. There is no magic formula to getting referrals. The power of word of mouth is undeniable despite Facebook and Internet ads. It is naïve to think that you can ask your partners to send you patients if they are too busy. It takes time, effort on your part, and miles on your car to meet primary care doctors and specialists more than once. After each case, you need to do three things: dictate the operative report, talk to the family, and finally, call the referring physician. Look to build your referral base away from your partners' and expand the practice by bringing new patients and not shoveling them around.

MAKE TIME TO STUDY FOR YOUR BOARDS

Completing your boards during your first 2 years of practice is not only a mental relief but also a major boost to your credibility and confidence among your group. In my view, preparation courses are a waste of time and are certainly costly. In order to pass your written boards, you should be proficient in all aspects of noninvasive vascular testing (vascular lab) and have access to VESAP (Vascular Education and Self- Examination Program). Just like the oral boards in general surgery, passing the vascular oral boards is dependent not only on knowledge but also performance and mental capacity. Practicing with another person is advisable, and going through one textbook is certainly recommended (eg, Ernst and Stanley's Current Trends in Vascular Surgery is still a favorite for examiners despite being outdated).

DON'T OVERSPEND

I cannot tell you how to run your finances, but I might be able to tell you that you shouldn't feel too comfortable during the first year or two on your job. Do not buy a house during your first year because you may find yourself relocating if things do not turn out the way you or your partners planned. Similarly, do not plan too many fancy vacations because this would certainly interfere with the image you are trying to convey of being the hungry, blue-collar, willing and able vascular surgeon. Instead, invest in your institutional investing plans (403[b], 401[k], etc.).

MAINTAIN A HOBBY

You may now have the time and finances to support your hobbies. Trying to play sports once every 2 weeks is a good start. I would recommend sticking to the basics and keeping it local. Whatever you decide to do, you can take this time for yourself away from work and the house and turn it into a healthy routine that you can actually look forward to on a regular basis.

MAKE TIME FOR YOUR FAMILY

You might have explained to your significant other or your family that your time is not really yours but your attendings', and you will be gone for what seems like days at a time. Now that this is no longer valid, you will quickly rediscover the beauty of having more time for your family. It is easier said than done given that you want to always be present on the job, able to stay late and do cases, take extra calls if need be, and yet manage to keep your household happy. I think a good way to balance this is on the weekends and long holidays when you can plan an activity or a one-day road trip. This will take you away from work and also bring you closer to home and enjoy quality time with your family.

Firas F. Mussa, MD, is an Assistant Professor in the Division of Vascular & Endovascular Surgery, and a member of the Section of Value and Comparative Effectiveness at New York University Langone Medical Center in New York. He has disclosed that he is a paid consultant to Medtronic, Inc. Dr. Mussa may be reached at firas.mussa@nyumc.org.