- Pass your boards and get your licenses. Board eligibility has the shelf life of a sack of dog food. After about two or three years, you better throw it out. While your apprenticeship with me and my partners has given you insight into the various styles and techniques of repairing arteries and veins, no hospital or insurance company will let you touch a patient without eligibility or certification. And while you are at it, maintain your certification with CME’s. Apply for licenses early and diligently. You are like newly hatched baby sea turtles and the ocean is your board certification.
- Look the part. Stand up, look people in the eye, smile. Stay well groomed and wear clean clothes. Scrubs are acceptable only on days you are operating in the hospital, but no one should see you at the grocery store in them. Dress professionally, but don’t spend more money than your peers or partners. Clean fingernails a given.
- Remember, your first job is not like a first spouse and may not be forever. Exit strategies at a basic that can be negotiated from the start is coverage of a tail policy upon mutual separation. Triggers for retention salary (never bonus which is taxed differently) can be negotiated. For example, you take a rural job away from people you might want to marry –you may put in your contract that every year after a certain number you aren’t married, you get a raise. Same with partners who are said to be near retirement –people live longer and want to work longer, and you might find that promised increase in volume and salary does not come to fruition. Contracts can be structured for retention salary increases in those instances. Hard to recruit areas need to recognize that and be willing to increase your salary based on volume that would otherwise go to another partner if they could recruit them.
- While it can be viewed as a business transaction, you are setting out to take care of people in a community. Cultural competence is a huge advantage if you are not a native. Understanding the reluctance of an 80 year old Iowa farmer to get surgery in the fall because of the harvest may give you insights to head off argument –their fine sons or daughters may come home and help organize the harvest. Part of the process of getting to know the community is establishing some roots –I don’t mean marrying the mayor’s daughter or having three kids out of wedlock. It means joining clubs, churches, community organizations. It means attending the local fairs and buying from local stores even when Amazon would be a lot more convenient.
- Towns can be measured by metrics. How hard is it to get to New York from where you are. Is it in fact New York? How hard is it to get to your town from where your loved ones are? What is the swankiest brand of car sold in that town. Is sushi made by Japanese, is dim sum by Chinese, the pho by Vietnamese? Is there Korean food? Is there a Whole Foods? Is there a functioning public transportation system? Can you get fresh fish? How many pro sports teams are there? Is there a college nearby that you have heard of? How fast is the internet? Is there cell coverage? Do they drink the tap water? Is there a meth/heroin/oxycontin problem? Is the highest paid person in the state the football coach?
- Learn the limits of your hospital, your ICU, your floors, your consultants, your office staff, and yourself in equal measure of importance. Be patient and stick to simple straightforward low risk cases if possible and have partners co-scrub more challenging cases. Find and know the regional referral center if you are in a community hospital and don’t feel shy about referring patients beyond the capabilities of everything in the first sentence. Your results will be under a microscope, but the most important watcher is you.
- Take care of yourself. Exercise, eat right, and take up a leisure time activity that won’t result in lawsuits or court ordered DNA tests. Golf is great. Vacationing is okay, but spending every moment of time out of town sends the wrong message. Budget and start saving for retirement because you won’t be doing this forever. Pay down debts and don’t take on unnecessary debts. You don’t need a Porsche or a McMansion. If you have kids, stick to public schools and live modestly unless your spouse has a lot of money, then you’re a trophy spouse!
- Low hanging fruit of publicity –eating meals in the doctor’s lounge, chatting with staff in the OR lounge, attending staff functions, joining the local medical society. The ten minutes of conversation over a stale sandwich or rubbery, overcooked chicken works. Make sure to have business cards handy or your contact set up to share easily by text or email. Pro tip: having pens printed with your name and practice and number –the equipment and drug reps can’t give you swag but you can give them swag to give out. Give grand rounds or CME talks. Bring in your former faculty as guest speakers. Get an article in the local paper –it will end up on the web site, but mostly older people, ie your patients, will read actual papers. Social media and the internet –unless you are deeply committed to keeping a live presence there with frequent posts and comments, don’t bother. There are too many practice websites and doctors blogs that get refreshed every 3-5 years that they are a liability. You need to blog weekly or FB, Tweet, and Instagram post daily to get a following. That said, done right, you can control your image far better than the hive mind will. The people reading the internet won’t be your vascular patients, but it will be their kids who will search you out on the internet. The other tactic is to never, ever be on the internet.
- Humans, from the time of the Australopithecines and maybe before, are organized through direct personal relations in groups numbering up to ten or twenty. You will be in control of an OR or an office, and you have to learn how to do this well to be effective, and it will depend on forming good working relationships. This is not easy and mistakes will be made, but ultimately your success will depend on how well you orchestrate your team. Buying pizza for the team is a good way to get pizza for yourself, but will also earn the gratitude of your people.
- No amount of preparation on your part will make up for problems outside of your control. When managing these by “taking ownership,” usually by starting committees and study groups, takes up increasing part of your day and happen without compensation or acknowledgement, it is time to move.
- Surround yourself with smart competent people. No referral stream is worth the trouble of associating with stupid, incompetent people, because ultimately, you will become one of them. That said, graduating at PGY 5-7, maybe more, means that you are likely the most trained, most up to date individual in the medical community and to the degree you have to live and work there, you have to give something of yourself to take care of patients. If that means admitting a complex patient with an unrecognized exacerbation of a connective tissue disorder because they were referred to your clinic with foot pain, it may be simpler to simply admit the patient to your service and start the care and workup rather than trying to do an outpatient turf. Sending this patient to the emergency room or dismissing the patient with instructions to set up a specialist appointment washes your hands, but you are not taking care of this person are you?
- You are being paid to be smart and competent at vascular surgery like LeBron James was brought back to Cleveland to revive it economically and redeem its souls from perdition. Act accordingly.
A Surgeon's Notes 