The Unwritten Rules of Surgery: Everything You Didn t Learn In Residency

Transcription

1 The Unwritten Rules of Surgery: Everything You Didn t Learn In Residency Value Proposition: Advice for young resident (or more experienced) surgeons on all the complications and common mistakes made outside of the actual surgery, and how to avoid them. INTRODUCTION Hook: David s Story How was the process of finishing residency and starting life as a surgeon for you? When I was finishing residency, I was clueless. It was only with time that I figured out what I didn t know I was fortunate. I learned from others, I did an MBA, and even so I just narrowly avoided being taken advantage of in my early contracts What s the pain of not reading this book? Surgeons tend to follow a track that s normal and, because they aren t prepared for the decisions they have to make, they end up missing out on big opportunities They end up being taken advantage of financially They end up getting stuck in a bad contract They end up unnecessarily overworked and overstressed They end up unemployed because they don t understand the system What s the pleasure of reading this book? By reading this book, you can avoid all that. This is the course that they should have taught in medical school to prepare you for your upcoming life as a surgeon. Not only will this book teach you how not to get taken advantage of, but it ll also open your eyes to all the potential opportunities that you can explore in your surgical career. What will this book teach you? In Part 1, you ll learn how to choose a type of practice that makes sense for you, how to find a job, and how to negotiate your first contract In Part 2, you ll learn how to prepare for your job, what paperwork and licenses you ll need, and how to make sure you re ready for orientation In Part 3, you ll learn about your life on the job, how to make sure you are succeeding based on your hospitals metrics, and how to use the internet and social media to boost your career

2 PART ONE: GETTING YOUR FIRST JOB Chapter 1: Types of Practices The Trade off: Traditional Practices vs. Non Traditional Practices Back in the day, the corporation was your family and they would take care of you when you retire. But that s not the case anymore (very few work for one company their whole life and retire from there). The average surgeon has ~6 jobs in their career The big choice between traditional and non traditional depends a lot on whether you re a self starter: are you willing to take risks and be different? Pros: Risk, more complication Cons: Be your own boss, work on your own time The biggest thing that stops surgeons from exploring these other options are the golden handcuffs of a good job. Once you have a good, high paying job (especially if you have a family, mortgage, etc.), it s hard to take the risk of leaving to be a self starter. So, if these things appeal to you, it s worth trying them out early in your career while you can afford to take risks and experiment. Locum Tenens What is it? Who is it good and bad for? How to get jobs? Go through a matching company (and, preferably, a company like his that also helps with all the rest of the details) Feel free to try them all! Because you re a freelancer you can serve multiple companies at the same time How do I succeed at Locums? Get armed with all the right information before! Where to eat, people s phone numbers, how the practice runs, what it s like there, etc. How to maintain quality? It s usually not a functional system you re working at, or they wouldn t need you How to maintain reputation? How to maintain quality? How much to locums surgeons make, compared to traditional ones? There s no data on the locums industry as a whole, but in general, locums surgeons will make more per hour, and they should be able to fill their schedule The problem is the taxation, so it s important to set up a corporate entity in order to make sure your take home income is higher There s just a wider variance Starting Your Own Solo Practice What is it?

3 Who is it good and bad for? Not for everyone! Although lots of people get excited about the idea. Realistically, you should only do this if you are entrepreneurial and have extra education in business to understand how to run it Not possible for people with golden handcuffs who have built a life around their high salary and can t live without it, because your practice will struggle at first. Usually it takes several years before you see a meaningful return Keep it mind: Like every business, it s likely to fail. You need to be okay with that or else it doesn t make sense for you. What tools should I use? The Business Model Canvas (canvanizer.com) SurgicalBusinessModelInnovation.com Stanford Courses on Coursera.org What s the ideal team size? How do you get funding? Why would someone do this? It s very fulfilling to work for yourself and build something from scratch Typical Surgeon Job There are a ton of details the rest of this book will dive into them Chapter 2: Finding a Job Most people put much too little thought into their potential jobs. It s a major life decision and impacts everything else in your life, so take your time and choose carefully! First, sign up for websites like DocCafe to gather a big list of possible jobs. You can also include jobs presented to you by recruiters. Some recruiters will work for companies, while other will be in house for specific hospitals; in either case, don t jump on opportunities just because they present them well. Add them to your list and slowly consider your options. What s the best way to do that? Create a scoring system, taking into account many factors Lifestyle What lifestyle factors should they take into account? Practice Type Are you interested in Locum Tenens or starting your own practice? If you re looking for a traditional job, do you want academic of non academic? What are the pros and cons of academic practices?

4 Pros: You get to do research on the job instead of just surgery, the environment is stimulating and challenging, you re judged not just on RVUs but also research output (h index or hersh index), you can get tenure Cons: Academic environments pay less, there are more constraints and fighting, and productivity tends to be low Work Life Balance How many hours are you expected to work? How often will you be on call? For what periods of time? Are they able to explain your prospective schedule to you, or is it unpredictable? Geographic Location Where should you move? For most surgeons, the state you train in isn t the state you work in Many surgeons go back to where they or their spouse grew up Which states are most frustrating to relocate to? Licensing is very different depending on which state you re moving to Hawaii, Oregon and Florida are the worst bureaucracy Other things to keep in mind when moving: What s the cost of living in the state? Are there other job opportunities if you lose this job? What are the barriers to get into the state? Salary What is the range of starting salaries for a surgeon? How much should young surgeons care about their immediate salary? What could the entire scoring system look like? Give an example. Once you ve figured out your priorities and where various hospitals lie in your scoring system, try to generate as many options as possible. Go for many interviews, speaking with all of the hospitals that are of interest to you and learning about them and what they would offer. We ll cover the importance of this in the next chapter on negotiations. As a worst case, you should explore locums tenens. As discussed in the last chapter, it s a great way to test drive many hospitals and learn what you like, and many hospitals use locums as a working job application and make full time offers to the best surgeons they work with. Chapter 3: Negotiating Your Contract

5 Figure out your worth Where to research salaries? What else goes into the calculation? What does a contract look like? What are the most important pieces? What are completely necessary pieces? What will hospitals tell you that isn t true? How does your salary work? What makes a good surgeon? It used to be AAA (availability, something, and ability), but that s very difficult to sustain nowadays, where it s more about how you fit into the organization that you re in. Usually, you ll get paid a base salary plus RVUs (although, they usually won t tell you how the formula works, you ll just know that RVUs are what s guiding it) Emphasize how ridiculous this is. It makes no sense... What are RVUs? Relative Value Units: Quantifiable measurements of how much a surgeon works Started off as a unit consisting of 15 minutes of outpatient clinic visit time, but difficult to evolve to surgery, so they did a survey in order to estimate (fact check this) The problem with this whole system is that the number of clients you see (and thus, RVUs you work) is largely out of your control If the top of the funnel is too small, it doesn t matter how fast or efficiently you work you aren t the rate limiting thing! How do you negotiate your salary? Have a strong BATNA (Best Alternative to Negotiated Agreement) Part of the reason to go for various interviews is to find the job that s best, but it s also to generate as many options as possible so that you re in a strong negotiating position. Being in a position where you are genuinely willing to walk away is better for negotiation than any tactic you can learn. Recourse to Objective Benchmarks (from Getting to Yes): Start with 5 or 6 things that you want to get out of the deal, but that you are willing to sacrifice for boosts in other areas. As you give up these things, these extra benefits are logrolled down, usually into salary. What s an example of resourcing to objective benchmarks? Anchoring: The first offer that s put out when negotiating has a huge impact on what both parties think is fair. How can surgeons apply the idea of anchoring in their negotiations?

6 Modern negotiating is mutually beneficial and about finding common ground, not steamrolling each other, so [insert applicable lesson] Should you get legal advice? Having a lawyer read through your legal documents can be helpful and allow you to catch any legal mistakes that aren t in your favor However, there are many things that a lawyer won t catch because they aren t familiar with exactly how hospitals and measurements work The truth is, everyone gets their brains stolen on their first contract. This book will help you explore some opportunities, and lawyers are useful, but the best thing you can do is ask for the advice of an older, more experience surgeon. How do you organize your taxes? Creating an LLC for yourself often makes sense to minimize taxation Who should do this? How do they go about doing it?

7 PART 2: PREPARING FOR THE JOB Chapter 4: Licenses and Paperwork Unless you re in the same state that you trained in, there will be tons of paperwork to deal with, and most hospitals won t help you through the process. The basic paperwork to prepare for: What are the pieces of paperwork that hospitals will require? How much time can you expect to have to spend on licenses and paperwork? There are teams that will help you through this that are highly recommended Top recommendation: Provider Lifestyle Experts How does working with a team like this work? Chapter 5: Orientation Day Orientation day (which can be more than a day in certain places) follows a pretty set formula. You ll be given a physical What should they be prepared for? Some hospitals test you for alcohol, so be sure not to have a glass of wine or a beer at lunch, or you ll be put on watch for alcoholism You ll get some basic orientation and computer training This can be long and arduous What should they be prepared for?

8 PART 3: THE JOB Chapter 6: Life on the Job Work life balance is very tough for a surgeon, because your schedule is so all over the place. Have a supportive, understanding family (having a significant other who is in medicine can make that understanding easier) Try to pick a job where you at least know how much you re going to work so you can work around that schedule This is where the trend is going. Millennial surgeons look at the world differently and expect that they will have some understanding of their work schedule. Realistically, the job is NEVER what you thought it would be Expect the unexpected: you ll be on call more often and for different things than you were told, and that s normal Hospitals are filled with internal politics, especially battles between groups to claim different procedures Example: Gastroenterologists passing rules around endoscopies (like minimum numbers) to stop surgeons from doing them so that they can keep their work McClelland s Needs Theory: What motivates people is power, affiliation with the team, and achievement. As a surgeon, put a priority on finding a team where you can find these things. There should be independence, there should be a team identity, and there should be rewards for success in the team members. Burnout is a lot more common in surgery than we recognize (as is substance abuse) because of the high stress. Some solutions: Have something else, like a hobby, a side business, a topic to learn about, etc. Learn how to turn off surgery when you re out of the operating room David has done complementary things and it s worked well, but not sure if he d recommend it There is also the ability to dive into non surgery based income: side businesses, rental homes, writing books, etc. It s easy to get demotivated by the fact that people should be dealing with their problems through preventative care and could avoid all these surgeries. The Federal government makes a budget for medicare, and other insurance companies base their payments off of that, which ripples through the whole industry. The government only agrees to additional spending if it will break even in the next 5 years, and this limited timeframe makes preventative measures a bad ROI.

9 Chapter 7: How You ll Be Evaluated Quality measures in healthcare are in the dark ages. They generally fall into one of two camps: national standards or internal metrics. National standards are purchased by hospitals for upwards of $70k a year. The most common of these is called NSQIP. Here are some basics: The most important metric is the O:E ratio, which measures the observed number of problems (which can be anything, like would infections), and compare that to the expected number based on their national data Even though these metrics make sense, they re only as good as the data you put in, which in most hospitals case isn t very good Other hospitals use internal metrics that they think do a better job of capturing quality, but often end up being even worse. Because these measurements are so statistically unrigorous and the measurements are not things that ultimately reflect quality, they can be very misleading and harmful, for example: What percent of the time does a surgeon respond to the emergency department consult within one hour? What percent of the time are patients discharged within 2 3 days? What percent of the time does a patient gets scheduled within one day? What percent of calls are answered within 3 rings? Communication of all of these metrics with the surgeons is very bad. Often, hospitals won t even tell surgeons their ratios or what they mean, only tell them there s a problem when it comes up. Quality metrics usually aren t in your contract, but the hospital will have the right to fire you over these problems because of clauses buried in the Other Duties section of your contract, which says that you need to participate in hospital improvement There s also a public national database that measures hospitals by division. It won t single you out, but if you re the only surgeon in a certain field in your hospital, your metrics will be publicly available. What s strange about this is that there is a real incentive for more quality. The government holds money for more minor things, and the problems and costs of low quality are even more expensive Hospitals should realize that they stand to gain a lot from fixing these problems, but because they don t show up on their balances sheets, they don t take them seriously enough and tend to stick with the status quo What does all this mean for a new surgeon?

10 Learn the metrics that matter to your hospital, and make sure that you re at least meeting the arbitrary goals set for those metrics Chapter 8: Building an Online Presence Social media is very underexploited among surgeons 10% of physicians use social media, and of those only 3 4% use twitter [check stat] Why bother building an online presence? Doesn t tend to bring in clients (especially in the short term) Builds legitimacy when other administrators look at the profile If you change jobs, it ll help you through that process David just got an awesome job on a board at a hospital [?] because of his blog on business model innovation in surgery Hospitals will use social media to appeal to people s elective surgery, where patients get to choose which hospital they go to for surgery Blogging Blogging is better than social media because you own the content you put on your blog! Setting up your blog... Go to GoDaddy.com, buy a domain, host it on there, install Wordpress Link to a GoDaddy tutorial to teach people how to do this Write blog content Write about whatever you think would be useful for other people Surgeons have the same problems repeating, so if you explain the solutions that you ve found to your problems, it ll be useful for other surgeons Never put anything patient related! The best blog entries are ~1500 words, use headings to break it up, include lots of pictures SEO basics... What is SEO? Enter keywords in the Title, Description, H1, and content You can pay third parties to help do this by writing and linking to your blog, which can be purchased through peopleperhour.com and odesk.com Make sure that your blog posts all link to each other Twitter Tweet out your own articles, but also other news that would appeal to your audience Tip to make it easier: Tweet Adder + URL shortener What makes a good tweet? HBR says that the most effective tweets (1) phrase it as a question and (2) include a photo

11 Canva.org and Placeit.net, which let you put images onto photos of people on their computers or phones Don t screw it up! Social media can be dangerous because it s so easy to do, so be careful! Get to know your hospital s social media policy so that you stay out of trouble If your hospital doesn t have one, you should contribute in making one Don t make negative comments about your organization or your patients

12 CONCLUSION [Fill in conclusion]