I want to thank you very much, Dr. Caldwell, for welcoming me to this course. And I want to thank everybody here for the next 30 minutes that you're going to share with me of your time. And I hope that I will make this very, very useful for you. My goal is to help share with you the most salient and important points that I can cover in 30 minutes about how to evaluate a practice opportunity as a young neurosurgeon. Some topics that we're going to cover today, they're the basics, setting your priorities, which will help you decide which jobs you want to take the time to interview for. Because you have very limited time for all the time that you spent in training to choose where it is you're going to make a site visit to. So you want to choose carefully based on your most important priorities. Some common mistakes that we see over and over again every year that people make in choosing a practice. They're easily avoidable if you are conscious of them and willing to admit to yourself if you're about to make one of these mistakes. I'm going to speak very briefly about compensation with the caveat that there's a lot more to say on this topic, which I think that some of the other panelists are going to cover about specifics of compensation with respect to independent practice and hospital employment as well as academics. And if anybody has specific questions, you can always call us at Rossman Search. How to compare positions, especially when you're looking at a hospital-employed position versus a position with an independent practice group. Different employment models and how that impacts things like the control that you'll have over your practice as well as your compensation. I would like to speak very briefly about how to use the interview process, the telephone interview and the site visit, in order to effectively evaluate a practice opportunity, when to talk about money and those good things. And also, I'll say a quick word about using a contract negotiation also as an opportunity for you to evaluate a practice opportunity and for the people that are interviewing you to evaluate you as well. So priorities, what are your priorities? Most people, when they are looking at a job, have four major priorities. One is the location, where it is. Two is, can you develop the kind of practice that you want in that particular practice? Three is the people, do you like them? Are you about the same things? And four is money. The location is absolutely critical. Your practice is going to be dynamic. In fact, it's going to change the minute you walk in the door. You will change the practice that you are joining. And your practice will change and develop over time, but the location is constant. When you move there, that's where you are planted and you're going to put down roots there, hopefully. However, no matter how much you like the location, if you cannot develop a sufficient surgical volume, you will wind up leaving. And if you can't get along with the people, either you will leave or they will leave. And if you're the new kid on the block, guess who's more likely to leave? Everybody thinks it's going to be somebody else, but it's actually you. So I don't want that to happen to any of you. I want to reassure you that although there are a lot of pitfalls in looking for a job that are pretty common, I have never had this call. People are so worried about money, but I have never had this call. I've never had somebody call me and say, Judy, I really need your help. I need to get out of my practice. Now, don't get me wrong. The people are great. I love my partners. And I have so many cases. I love my practice mix. I love my patients. The referring physicians love me. It's really a good setup. And my family is happy here, but I am just not making enough money. You have got to help me get out of this mess. Never had that call. You all are neurosurgeons. You're going to make a lot of money by anybody's standard. Even if you could make a lot more money somewhere else, if you get the basics right, which means the people, the practice, and an acceptable location, you will be happy enough to stay, I promise you. So common mistake number one, we have already alluded to, which is focusing so strongly on location that you forget that you need a good job. And every year I hear from people who called me the year before, and they said, I only want to be in Miami Beach. It's the only place I want to look for a job. My fiance is a runway model, and she requires that I have a job in New York City. I advise them to find another fiance, but they don't listen. You know, I really need to be in this little area of Michigan. You would think they would need neurosurgery. They would figure out how to find a really good job there, right, but the hospital doesn't always know how to manage a neurosurgery practice in that small town in Michigan. If you focus so heavily on geography that you forget that you really need to be able to develop a successful practice, you're going to create problems for yourself, and you will wind up leaving. Another common mistake, which is usually caused by one of two things, is this mistake. It results in this phone call. Judy, I need your help. I need a referral to a great medical contracts attorney. I need an ironclad contract. You need an ironclad contract? Well, I'd like to see one of those, because there is no such thing. Who here thinks that a contract can actually force somebody to do what they've promised to do? Can a contract force somebody to do something? No way. All it is is evidence of an agreement. It is nothing more than that, and it can set the legal penalties for what happens if you don't do what you promised to do. And in order to even get those legal penalties, even if you agree on it, you have to be willing to sue on the contract. Who wants to sue their employer? Who would like to remain employable if they choose to leave? You never want to sue your employer. I will give you a piece of advice that will be valuable well beyond even looking for a job in neurosurgery. I am a recovered attorney. Don't hate me for being a lawyer. I'm fully recovered. But the first day of contracts class in law school, I had a wonderful professor, Stan Henderson, and he shared with us this advice. He said, I am going to tell you the most important thing that you will ever learn about any contract, and I'm going to tell you while I'm standing on one foot. We said, great, this is going to be short, and we're going to be done. So we all paid attention. And he picked up his foot, and he balanced a little better than I will. And he said, the most important thing about any contract is the people on both sides of that agreement. If you get that right, you have no problems. If you have a turkey or an incapable person on either side, you will have problems no matter what the contract says. So do not look for an ironclad contract. Look for people that you trust, that you can do business with, that you can work things out with, who will respect you. Another common mistake is ignoring difficult politics. Why do people ignore difficult politics? They do it for one of two reasons. Either you really want to be in that location because it is South Beach, and everybody there looks really good in a bathing suit, or you ignore it because you really want the money and they are offering a lot of money. The most common situation where this is a problem is where there is a very successful independent private practice group that is serving a hospital, and the hospital is sick to death of paying through the nose for call. That's the most common situation where I see young neurosurgeons and senior neurosurgeons run into trouble when they look for a job. The hospital is going to pay a lot of money for somebody to come in and be their person to establish a group to take call and break what they perceive as the stranglehold that that independent group has on them that allows them to demand a lot of money for call. That is a risky proposition for you. That's why they're willing to pay you so much money to do it. Also, if you come into an interview situation and you sense that there's a lot of tension between people in the group, especially if you have a situation, for example, where the younger people say, I don't know really why they brought you in to interview because there is not enough volume here for me, so there sure isn't enough volume here for you, right? Those are big red flags. Also, if you're interviewing for a position where the practice or the hospital has had a lot of turnover, what do you think you should do? What do you think you should do? Call the last person who was there. Do you know how often people take that advice? Like almost never. Why do people not take that advice? Because you don't want to hear anything negative about a job that you're really excited about. Trust that you are brilliant, otherwise you wouldn't be where you are. Trust that you are intelligent. There are two sides to every story, sure. Hear both of them, and then you can decide how much stock to put in each side. Another common mistake, signing up for an income guarantee that is not sustainable. Who's heard about this problem? Anybody? Anybody worried about it? Okay. So, who knows? Does everybody know what I'm talking about when I talk about an income guarantee? Because I'm not talking about a salary. Okay. I am talking about a term of art for a forgivable loan that a hospital will extend to help a physician to help induce a physician to relocate to their community to serve a community need. It would be a lot less attractive if people would call it what it is. They call it an income guarantee. It is a forgivable loan used to induce you to come and practice in an area to serve the community need. Now, I don't want you to be so scared of an income guarantee that you would never take one. Sometimes it's fabulous. It can be free money for you. But it has to be sustainable. And the group has to be good enough that you're going to be staying because there's always like a payback period where you don't have to pay back if you stay X number of years. There's nothing wrong with an income guarantee as long as the income is sustainable when the guarantee period is over and as long as you stay. And what's the best barometer of that? Find out what the other people in the practice are making. That's the best barometer of that. Another common mistake is accepting a hospital-employed position when you really don't know what your reporting structure is or who you're going to partner with when you have problems because inevitably you will have problems. As soon as the honeymoon period wears off, you will be introduced to your first problems. I'm an endovascular neurosurgeon. They promised me a biplanar. I was told it was going to be here when I started, and it's not. And three months later, it's still not, and six months later, it's still not, and nine months later, it's still not. I have spoken with the head of human resources who drafted my contract, and he doesn't seem to have the power to say, yes, I spoke with the mid-level manager, and they don't even know what I'm talking about. I showed them the contract. They said, talk to the CEO. The CEO has not returned my call in three months. What am I going to do? Know what your reporting structure is. Anticipate that you'll have problems and know who you're going to go to. Let's talk very briefly about compensation. Your compensation is going to depend on your clinical interests. If you love functional neurosurgery, do it. Don't expect to make as much as the spine surgeon working next to you. It's going to depend on how busy you are. Don't use the MGMA data to decide how much you're worth. You know how much you're worth? You're worth how busy you are. The best advice I can give each of you to ensure your economic security is to develop a busy and successful practice. That's the best advice that I can give each of you to be sure that you're going to make a lot of money into the future. It's also going to depend on where you live. Don't think that the people in California are trying to take advantage of you because they're offering you a much lower amount than the people in the middle of the mitten in Michigan. There are two major compensation surveys that you should be aware of, which is MGMA and NERVS. Those are the gold standards. MGMA has pay-for-call data. NERVS has pay-for-call data. Don't use the NERVS pay-for-call data. It's much better. There are more respondents, and it's broken up in a much more relevant way. There are other types of surveys also. Sullivan-Cotter is used by a lot of hospitals. It's also used by a lot of different entities. Interestingly enough, every year the Sullivan-Cotter data comes out, and the compensation data are lower than MGMA and NERVS. All wonder a lot of employers love to use Sullivan-Cotter. I think they're just using the data that favors them. Know these surveys. Know that there is also some subspecialty data available now through the NERVS survey. One thing I'd like to share with you about compensation is that a bigger compensation plan at the beginning of your career is only better if you plan to stay for the long term. A lot of times I get calls from people who are starting their careers, especially who are deep in debt. Some of you have so much debt it is stifling. I feel sorry for you when you're in that situation. You say, well, why don't I take this job where they're going to write off my loans and pay me a big salary, and I'll take that job for two or three years, and then I'll move. I would encourage you not to make that move. I would encourage you to think about your practice like a pyramid. The beginning years of your practice when you are getting yourself busy, developing relationships with referring physicians, hospital administrators, developing a reputation in your community, training your PA, making sure your OR team runs well, all those things. It's like building the base of this pyramid. Once you've built the base, it's so much easier to build up in your practice. If you know you're going to have to relocate, you're going to have to go somewhere else, and all over again you're going to have to build it. Tremendous amount of work to build the base. Have faith. You're going to make enough money to live, I promise you, even with a staggering debt burden. You will repay it in a few years, you just might not get rid of it all at once. Go somewhere where you think you're really likely to stay. Take your best shot at that. When you're comparing jobs, remember that if you're looking at the salary that a group is going to pay you versus the salary that a hospital is going to pay you, remember that the people in the group are not trying to take advantage of you by offering you much lower compensation than the hospital will. The hospital has an entirely different pot of money to deal with, to use, when they're deciding how much they're going to pay a neurosurgeon. They get all the facility fees, and the technical fees, and everything down to the $30 aspirin. The people in the group are like the people at your table. And if the people at your table, if you all were getting together and deciding how much to pay a new neurosurgeon, the first thing you would think is, well, how much is it going to cost me to employ them? And then how much are they likely to generate? And what is my break-even point going to be with them? And then once they've passed that break-even point, I'm going to give them a bonus. So remember, they're not trying to take advantage of you if they offer you a lower amount. And they might have a lot of important advantages to offer you. Let's talk very briefly about some of the pros and cons of hospital employment, which I know will also be covered in much greater detail by Dr. Bean. Some of the advantages, you don't have to run your own practice. But make no mistake, that's not an excuse to become uneducated or allow yourself to be uneducated about billing and coding. If you don't understand about the business of neurosurgery and collections, you will, at worst intentionally and at best unwittingly, be taken advantage of in your compensation plan. So you'll still have to know something about the business of neurosurgery, but you won't have to run a business. You are likely to earn a lot more money right away because the hospital has a bigger pot of money to play with. And the hospital is likely to have a much easier time recruiting partners for you than if you are in a private practice group and you have to recruit with many fewer dollars, far fewer dollars. Also, an RVU-based structure or salary structure allows you to be insurance blind, which is really nice because you're all physicians and you went into this to take care of people. If you wanted to go into business, you would have gone into investment banking. You're all smart enough. And you don't need to learn how to allocate revenues and expenses with your partners. And that's especially nice if you know yourself to be a challenging person to get along with and you know that you're not going to have an easy time making hard compromises with your partners. Some of the disadvantages, the most important one which nobody believes, you are an employee and you can be fired. And things that are important to neurosurgeons are not always the things that are important for professional success when you're in a corporate environment. To succeed in a corporate environment, you have to be able to go rah, rah when somebody says, this is the direction that the team is going. And you have to be able to get along with people really well, no matter how good you are. Being the best neurosurgeon in the world is not going to save you as an employee if you are really challenging to get along with. Also, your agreement can change when your contract term is over. And in fact, it could change before your contract term is over because every contract has an out clause. Usually 60 to 90 days, they can call you in and renegotiate your contract. You say, but I have a five year contract, but it has an out clause. What are you going to do, sue them? No, you're going to sit down and you're going to negotiate with them. That's what you're going to do. Changes in hospital administration might mean changes in your practice and you might have a lot less control over which neurosurgeons are hired as your colleagues. Different hospital employed groups have different, widely varying amounts of control over the neurosurgeons that join the practice and also the staff in the practice. There are some advantages to being an independent practice, although I know a lot of young neurosurgeons are nervous about going into private practice because of the prospect of continuously declining reimbursement, which is a very real threat. One of the best advantages is that it is likely to be a well-established group and offer mentorship for a young surgeon. And if you think about it, if you and the people around your table get together to hire somebody and you're using your own money to hire that person, how invested are you going to be in their success? Very invested in making them successful. You're going to have a big incentive to mentor them. But if the hospital is footing the bill, you might not have the same incentive to mentor them. So you might be in a much better position to receive mentorship. Not always, however. In a hospital employed arrangement, that could also have advantages about mentorship, especially if the hospital took over an existing group that was already successful. You will generally have more control over when you retire or choose to leave your practice if you are an independent practice. And the ability to admit to more than one hospital can give you very important leverage. One of the best and funniest negotiators I know says, negotiating is so easy. It's really not a problem. I tell the person in charge of purchasing at my hospital that I need a new microscope. And he says, yeah, sure, I'll put you on the list. Five months later, there's no microscope. I say, where's the microscope? He says, yeah, yeah, it'll be coming. It'll be coming. I go to the hospital up the street, and they're going to get me a microscope. So I do all my cases over there. I go back to the first guy, and I say, you know what? I have great news for you. I don't need that microscope anymore. And he says, oh, that's fabulous news. What happened? Well, people up the street at the other hospital got me a microscope. So we're doing all those cases down there. In fact, we did about 120 of them in the past six months. Oh, my god. That is negotiation without confrontation, because you use the leverage of having more than one admitting hospital to be able to get what you wanted. Also, as Dr. Woens is going to share with you, you can develop ancillary sources of income, which can help insulate you against some downturns in reimbursements. Some of the disadvantages. You will usually make a lot less money to start. You do need to eventually run your own practice or trust that one of your partners is going to do that effectively. You can't be insurance blind when you are in private practice. Reimbursements and malpractice are very likely to impact the way that you practice. You have to figure out how to get along financially with your partners, which is often challenging. And I do know surgeons who have tried to develop surgery centers and other ancillary sources of investment, and they have not been successful. They've lost a lot of money. All of the pros and cons and all the talk about comp always gets people nervous. Don't be nervous. You are going to be very, very successful, each and every one of you, if you focus on the basics. Is the location acceptable to your family and to you? Do you like the people that you're working with? Can you develop a successful surgical volume? I guarantee you, if you get those three basics right, you're home free. You'll make enough money. You'll be happy enough. You'll stay. Proximity to family is something that is very easy to undervalue when you are young, your parents are relatively young, and your babies are young or you don't have them yet. Because your parents can come visit real easily without a walker or a wheelchair. They're not yet sick. They can come see you. And your kids are easy to cart around. And if they needed to move, they're not 13 and abandoning all of their friends in middle school. But it's important to think about what it will be like to be far away from your parents when they are aging and they're missing their grandchildren. And you're missing being able to be with your parents when they get old. You want to take care of the people that you love. It's natural. Of course, not all of us want to be that close to our family. And some of us have very important reasons for wanting to impose the 500-mile rule, right? No closer than 500 miles to my family or my mother-in-law. There are some questions that you can use to evaluate a practice opportunity during your telephone interview. None of these questions involve how much vacation do I get? What is my schedule like? What is the call schedule? How hard do you all work? Ask people, do you mind telling me what your needs are? Why are you recruiting now? What is your goal? Tell me what you're looking for in a new hire. Make notes about what it is they need, because you're out there to get a job offer. I mean, you want to evaluate the opportunity. But the last thing you'd want to do is evaluate the opportunity and think it's great. And then you didn't get the offer. Somebody else did. So remember that when you ask people what their needs are, you are developing talking points for your site visit to impress them that you can serve their needs. Ask them what types of cases they're doing and whether they want more of the same or whether they're looking for somebody who can expand the types of services that the practice offers. Ask them how many hospitals they cover, and ask them to tell you about the hospitals. Those are nice telephone interview questions. On your site visit, you can be more probing. And the most important thing that I want you all to get out of a site visit is this. What are the values of the people in that practice? What is that practice looking to be when it grows up over the next five or 10 years? Are you all about the same thing? Do you share the same goals and the same vision? That's really what you want to get out of that site visit. And you want to probe gently about what are the relationships like between the surgeons in the hospital, whether they're employed or whether they're an independent practice. What are those relationships like? How supportive of the hospital? How supportive is the hospital of the surgeons? Has there been turnover in the practice? Who left? Why? Hear their side of the story. Remember, you're going to chase that person down. You're going to call them, and you're going to hear their side of the story, too, even if you don't want to hear what you think they're going to say. And then you can decide how much stop to put in that. Find out whether there are any ancillary income sources for the practice, if you're interested in participating in them. You don't have to really talk about buy-in right then, but you sure have to understand that before you sign on to the group. Ask about available mentorship. I wouldn't really ask that too much on the phone. In my experience, it sounds like it lacks confidence when you ask on the phone. But when you're in a site visit, and they can see that you're in person, you're a confident person, you're really asking not because you're a weenie and you don't know how to operate. You're asking because you value the experience of the experienced surgeons that you are joining. That's a good time to ask about mentorship. Now, here's what everybody wants to know. When can I ask about money? When can I ask about vacation? Focus the first visit on learning about the practice and the people and their needs, what they're looking for. On the second site visit, it's perfectly OK to ask about what an offer might look like. And a nice way to ask that that doesn't sound presumptuous is if I am fortunate enough to be extended an offer to join their group, would you mind sharing with me what the compensation package might look like? Understand that it's an honor to be given an offer, whether or not you want the practice opportunity. Treat it like a gift. How would you react if somebody gave you a gift and it wasn't really what you wanted? You wouldn't turn your nose up. You would say, thank you. It's an honor to be given a gift. My advice is unless you have family overseas and you really need to have significant time off to see them, don't ask about vacation at all. If you do need to ask about vacation because you anticipate significant overseas travel, you can call me about it. I'll give you some nice ways to ask about it while making it very clear that you're a team player and you're going to take every 4th of July, every Christmas, every Thanksgiving, every everything in exchange for having the time off that you need to go overseas. I think the vacation and the benefits are going to be clear when you get your job offer if you get one. And if it's not clear, you can clarify them. The key question, and we're almost at the end, is can you develop a successful surgical volume? And I want to share with you that a lot of people put a lot of stock in this number, one neurosurgeon per 100,000 people. How many people have heard that number? Anybody? Right? This came from a 1974 study published in 1975 by the US government. And it was based on nothing, as far as I can tell. In fact, they came up with the same guideline for every single surgical specialty. I think it was based on a political agenda of reducing the number of physicians that we were training. It doesn't tell you anything about your ability to develop a successful surgical practice. What will? What will tell you the all-important answer to the question that you have? If you're looking at a hospital-employed position, I'd like Dr. Bean's opinion about that. My thought is that the strength of the health system and how well-organized it is is going to have a lot to do with that. But I'd really value Dr. Bean's opinion. In private practice, certainly the most valuable indicator of your own ability to develop a successful surgical volume is how busy are the people who are there. Ask questions about support for the practice. I'm not going to go into this now because we're out of time. I just want to say one quick word about negotiating a contract. People often think, I have a job offer. Now I'm going to negotiate my contract. And sometimes they hire a bulldog of a lawyer to represent them. And I guess what I would ask you is this. Can you understand that it's part of the interview process? If somebody gives you a 10-page contract and you come up with 57 questions, and all of them seem to be deal breakers, can you understand how the people are going to perceive you? They're going to perceive you're going to be difficult to work with. They can revoke your offer. And that evaluation goes both ways. If you get a 35-page contract from the people and it has all kinds of stuff that is completely unreasonable and they are really unwilling to discuss any of the important stuff with you, you may very well decide that you're not interested in joining that practice because you're going to be working with a lot of very inflexible people. The most important take home you've probably guessed, focus on making sure you're in an acceptable location with people that you trust and could see yourself working with who share your values, where there are good indicators that you can develop a successful surgical volume. From that, all good things will follow. Thank you very much. Thank you.

practice opportunity

neurosurgeon

priorities

location

surgical volume

compensation

employment models