Voices of Experience: Advice to Medical Students, Residents, Fellows, and Young Surgeons

This publication represents the edited transcript of a previous Zoom Seminar essentially about what’s next: what to expect next, and how to prepare yourself for what’s next in orthopaedic surgery whether you’re a medical student, a resident, a fellow, or even a young attending.

We had the honor of having a remarkable group of experienced surgeons. Dr. William Levine, Dr. Joseph Abboud, Dr. Wael Barsoum, Dr. Matt Barber, Dr. Lisa Cannada, and Dr. Kevin Plancher. The session is moderated by Dr. Ira Kirschenbaum, the Editor-in-Chief of The Journal of Orthopaedic Experience & Innovation.

Dr. Kirschenbaum: What general life skills do you recommend for all orthopedic surgeons to develop through all their training years?

Dr. Levine: Well, I think there are three things that I tell students who are doing Sub-Is. People always ask, what are you looking for in your Sub-Is? And I say, well it’s actually the things that I look for in everybody that I hire. It’s pride, it’s professionalism, and it’s interpersonal skills. And if you add those three up and you can navigate those three, then you have a pretty good chance of putting yourself in a good position for every interaction that you have with patients, with the hospital support staff, with department staff, and wherever you happen to be. So those are my three things that I tell everybody that I look for and that they should focus on.

Dr. Kirschenbaum: Anyone else wants to chip in here before I call on people?

Dr. Plancher: Resilience. But Bill almost had an alliteration. I don’t know why he blew it on the third.

Dr. Kirschenbaum: Wael, you came from the Cleveland Clinic and now you’re an Innovation officer at HopCo. You see a lot of young people.

Dr. Barsoum: Yeah. For me, we all hear about the three A’s in medicine: ability, affability, and availability. And I really think that’s kind of good advice for life.

You’ve got to be good at what you do. So, if you’re going into a surgical field, make sure that you come out being the best-trained surgeon that you can be. I remember meeting with one of my mentors Les Borden, who was the head of joint replacements at the Cleveland Clinic when I was a resident, and sitting down with him and telling him I wanted to be an adult reconstructive surgeon and asking his advice about fellowships, and he said, your fellowship should be the place where you go from being a really, really good orthopedic surgeon to being an excellent orthopedic surgeon. It’s all about that surgery. So that was the ability part.

Affability. Being nice to people. You’ll see pretty quickly as you go into practice, people will be calling you. Especially, if you’re the kind of the first person on the totem pole there that gets that phone call, might be at 5:00 on a Friday evening. Always say yes. There’s a human being on the other end of that call that needs your help.

And availability. I mean, being available for folks, being nice to folks, that makes a really big difference for being successful in practice. And you know, many times the people that build the biggest practices initially aren’t necessarily the people that you might say are technically the most gifted surgeons, but they are definitely the people that make that combination of A’s the most successful.

Dr. Kirschenbaum: Any comments? Lisa, a few comments on this?

Dr. Cannada: I love what everyone’s saying and the three A’s are definitely always important. But I also think it’s important to be exceptionally affable, but really not over the top. Some people really try too hard especially when they’re starting. And that includes in residency, in fellowship, and in your job. Don’t try too hard, just be your good self. And learning people’s names is really important. I think that’s very important no matter where you are and what you do, and you really want to integrate. The three A’s help you integrate into whatever practice setting you are in. So that’s a really important take-home point from combining what Bill said and what Wael said for us to do.

Dr. Kirschenbaum: Joe Abboud. What do you think?

Dr. Abboud: All very important points, and I was just writing down Bill’s points because they’re really good. Everyone’s points were really good. But I really like how succinct he was. I think we’re so used to succeeding when we come in from medical school as residents that I think humility is very important. Learning that you have to work in teams. A lot of times in school, whether it be in college or medical school, you have something to digest, you study it, you take a test. It’s kind of just you. You’re the one person and you’re not working with a collective group of people, whether that be your residency class or office team. The psychology of teams and building a residency, I think are obviously very similar to what Bill is saying as far as building a good department, but we all know of situations where people are not necessarily very good residents, but exceptional attendings cause they don’t work well in teams or didn’t work well in teams.

I think those people are becoming less and less favorable as far as being attendings anyway but I think that having diversity of thought is very important in your group to make sure you have the ability and the safety to feel like you could speak among your peers and in your residency and to not be outspoken, but to definitely speak your mind openly.

Dr. Kirschenbaum: Kevin, what do you think?

Dr. Plancher: So once again, just to reiterate, I think everyone is on target but I’m learning that some of the skillset that came naturally for some of us that are sitting here is different, and the pressures that are there are different. And so, I would say coming from the signage Will knows of being a servant leader in the Cleveland Clinic is hard sometimes for some of the younger people to understand. And I think putting yourself in the patient’s shoes always is important because the stress is very high now and until you’re a patient, and I’ve had the misfortune many times, it teaches you a great lesson of, as Joe said, who’s in the team who you really need, and therefore, I think you become a better listener. So, I would add learning how to listen. Because the patient will tell you every day what needs to be done. And then remembering when you come home, wherever home is, to try to leave it at work and not bring it at home so that you still have that other part of your life.

Dr. Kirschenbaum: Matt, What do you say?

Dr. Barber: I think the points everybody’s made have been great and they’ve really touched on a lot of different things you ask for life skills. I think trying to have some balance in your life, have a home life that’s stable, whatever that looks like for you, being reasonably physically healthy, that gets hard during training, taking care of yourself in those regards… and having somebody during that training process and at the end of the day that really you trust and can speak to you and will kick you the real deal no matter what happens. And that a lot of times is a spouse, but it can be a trusted practice partner.

I’ve got a handful of people around the country that I can text questions to that are always going to be there and give me sound advice. Because you can go out and you can hear a lot of things and you can hear bad stuff about yourself or get your ego pumped up depending on who you’re willing to listen to. So, I would keep those in balance. And the other things that have been spoken about… I think the pride and the professionalism and how you deal with people are all super important.

The three A’s are classic. For better or worse, your affability is the most important if you’re talking about practice building. Your competence is presumed. Our skill, unfortunately, in a lot of respects, is seen as a commodity at this point. And so that part is just assumed by employers, by patients, by a lot of people to be the same.

And so there are some people that are not as great technically, and some people, quite frankly that are bad technically, that have built monster practices on really great personality and affability. So, combining all of those is important. But if you’re trying to grow it you got to be good to people. And it’s like Will said, you, you take the call at 5:00 PM on Friday, you’d be available and you’d be nice to people.

Dr. Kirschenbaum: That’s great. I just want to add a comment that when I did my fellowship it was with Richard Rothman and Rothman said to me, almost on the first or second day, every day you come into the office, do something better. Do one thing better. A better note, a better incision, speak to someone a little better. Every day, after a few years, you’re going to be that much of a better person. And I thought that was great advice because it keeps you on your mind like, today I’m going to do this. Today, I’m going to do that. And I think that works out pretty well.

What are the two to three things you absolutely need to consider in your first job hunt? What are the first couple of things you’re looking for in a job? What are the things you’ll look at, that you want to consider in your job? I’m talking about not the point of view of the employer, but the point of view of the job seeker. I’d like to start this with Wael because I know you work with a lot of practices now.

Dr. Barsoum: Yeah. First and foremost, I think is cultural compatibility, and that sounds like a cliche term, but you have to, I think, make sure that your goals and your life philosophy are consistent with that of the practice. So let me be more specific. If in your first interview. It’s clear that what somebody’s looking for is just a high volume, churn and burn doc that’s just going to come and crank out cases, and that’s not what you want to be, that’s not the right practice for you. So just making sure that what you want is culturally aligned with the practice is a big, big deal.

The second thing is your partners. And I would tell you that one and two probably go hand in hand to some degree. But again, making sure that you’re aligned with your partners from a personality perspective and also from a respect perspective. If you’re coming out as a spine surgeon and maybe you’re confident but not super confident, having a senior spine surgeon in that practice that is ready and willing to step in and scrub tough cases with you and go through cases with you, that’s a big deal. Very different than joining a practice where maybe you’re the only spine surgeon and you’re not quite ready in your own mind.

And the same holds true for the opposite, right? If you’re super independently minded and you are really ready to go and very, very confident and you want to go out there and light the world up, great. I mean, then being kind of the only spine surgeon in that practice may be a great way to build your practice more quickly. So, I think that alignment and cultural alignment is extremely important.

Dr. Kirschenbaum: Great. Some other comments from the faculty?

Dr. Abboud: I hate to be a cynic, but probably the first one is how to get out of the job. More important than a lot of the things that people look at like money and location, how do you get out of the job? I think you know we all approached things in different ways. When I did it, I went kind of through a little Excel spreadsheet of things that were important to me, and that wasn’t on there to be honest. I kind of learned the hard way my first job. But a lot of the other ones that will be mentioned are very important, but also your family. As a resident you may have a spouse or maybe even a young family, but you start to realize how much… at least for a lot of us, we need our family around for support and for guidance and being able to have confidants and help with things. That’s also important. So I think a lot of times people look at the renumeration immediately, but that’s probably the last thing I would recommend people look at.

Dr. Levine: I was going to say this is probably the most commonly asked question from all mentees, and we’ve talked to lots of people about finding your first job. The first thing I tell people is related to Joe’s, it’s a little less negative, but it’s a corollary, and that is 70% of all orthopedic surgeons leave their first job within the first five years. 50% within the first two years. So, if you look at that, you can either say, boy, that’s the most depressing thing I’ve ever heard. Or you say, you know what, this has taken away all of the stress of me feeling I have to find utopia.

The likelihood of finding a utopia is not very high. And the reason for that is that as I tell people all the time, finding your first job is very situational. You might want an academic job, but there isn’t an academic job in the geographic area that you’re looking for, or vice versa.

So first of all, take the pressure off. Second of all, you take the best job in the best area that suits you and your family and you get your boards under your belt, and then you move on if that’s what happens. And what Joe said is the other part of this that’s so important. I make sure that I sit down with the partner and, meaning the person’s partner, and say, look, this is not hypothetical. We’re moving to Butte, Montana because they’re paying me $1.5 million in the first three years. This is you’re opening the envelope and we’re moving to Butte, Montana. And if that’s not where your partner wants to be, they could pay you $5 billion and you’ll be a very unhappy person.

So I think you have to be very honest with your partner and make sure, because they’ve often been the ones who have been sacrificing for the five years of residency, plus your fellowship and they are like, “No, I’m done. We need to go to a place that is mutually beneficial.”

Dr. Kevin: So, I’d like to build on what Bill says that it’s a fact that we as orthopedic surgeons have no clue how to pick a job when 50% change. That means our EQ sucks. So, the point is that you really need your significant other partner or spouse to help in the process. Because I find it… unlike what Bill says, terrible, that you have to uproot your life for 50% of us. And so, thank God there are other jobs and people work out great, but I think it’s important that I don’t know that we see what we want. So, my adage is, you need to ask everything. We’re not trained as physicians and we get embarrassed to ask certain questions, and we should not hold back in a polite fashion to ask. It may be I need every third Saturday off, whatever it is. Well, we can’t do that, or it may be… Whatever it is you should be able to have an open conversation and ask the managing partner.

Any businessperson will tell you, they go in and they ask questions. I think Chuck Bush-Joseph said it best. I’m not offering the new partner anything. If they ask for it and it’s reasonable, I’ll give it to them. And so, I’m talking about any job, you got to ask. Because they’re not going to volunteer anything. It doesn’t work that way. This is business. There’s no emotion. It’s a contract that you put away and hopefully, you find the right place. But I would encourage the young people to say it’s okay to ask what the rules and the culture as others have said, because it is about the culture makes it successful that you have fun and you’re excited to wake up and go to work.

Dr. Kirschenbaum: How do you recommend dealing with the known stresses of residency? The known stress, or the unknown unknowns to quote Donald Rumsfeld. The residency has quite a number of stresses, not the least of which is applying for fellowships, but also just the hours and sometimes a toxic environment, sometimes not.

Dr. Cannada: Yeah, great question. There’s known and unknown stressors and certain things you have to realize is, what can you be prepared for and what are you not prepared for. One thing we know is that you’re prepared for your cases, you’re prepared for the clinic, and you’re prepared for conferences.

By being prepared, then you have less stress on you because you aren’t worrying like I didn’t… it’s like going into a case knowing you’re going to be asked questions and you didn’t prepare for it. There’s nothing more than increasing the stresses on that, and that might cause a whole cascade of events, meaning you might not answer the questions that the patient’s asking, you might not be nice when you leave the house, that morning to your spouse or partner or even your dog. You might just not be nice because you weren’t prepared.

So, the first thing to handle the stressors is to be prepared and learn how to prepare by using others in the residency and also in your network. So being prepared helps, but more importantly, things don’t always go right, so it’s how you handle the things that go wrong in residency that really determines your pathway to success in the future. When things go wrong, it’s important to keep everything in context. If there are mistakes made, you own up, if the environment is bad, what can you control? Can you make someone’s day better to perhaps, a little bit start chipping away at the problem. It’s important to know who you can trust and who you can’t trust, because if you try and dump things or discuss things with the wrong person, that can lead to a bad problem.

Also, build a team and build a team around you, a team that will help you with different aspects. That can be your home life. That could be your preparedness for surgery. That could be taking care of patients. So, build a team that can help you, because that also will help take the stresses off in residency. And really, it starts on day one. You have to enlist your allies on day one. And you also have to give something to them. Give back in your relationships. So, it’s really important, and one thing I always say with residents too, is they really think about their job versus their career.
You don’t want to think about it, it’s just a residency, but it’s actually the building block for the rest of your career. So, by succeeding in the small steps of residency and building from that then you really are building toward this successful career.

Dr. Kirschenbaum: Joe, you’ve seen your share of residents.

Dr. Abboud: Yeah, I think that… I wish someone had told me how frequent failure would happen as a resident. While you need to sort of reflect on it take it in, write notes for the next time, and try not to beat yourself up too much. I think sometimes we are really hard on ourselves. And that can lead us to burnout and even depression as residents and attendings. And you have to find your outlet, whether, whether it’s rock climbing or whatever. For me, it was hanging out with friends that were not in medicine when I had free time so I didn’t have to talk about medicine. So I could hear about their lives and just have different conversations. So those were ways I tried to cope.

This is great to hear and I think everyone that’s been talking has been through all of this and understands this. I wish I had a forum like this when I was a resident because honestly, I really had, in retrospect, no idea what I was getting myself into. And as you went through it, you’re just kind of like, that true fire hose just blowing water at you and you’re like, I have no idea how to deal with this.

And in the middle of the night, taking calls, walking around the hospital, thinking to yourself this night will end. And just repeating that to myself was a coping mechanism because sometimes you were just very, very exhausted and just wanted to just have some of the calls stop.

Dr. Kirschenbaum: Bill, a lot of residents go through Columbia of course, and how do they deal with the known stresses? What is your recommendation for dealing with the known stresses?

Dr. Levine: I can guarantee you that the words wellness and mental health were never uttered in the five years that I was a resident and the years that I was a fellow. So, thank goodness we’re in a different era. There’s a psychiatrist at Columbia who only takes care of residents, fellows, and faculty, and she’s on speed dial and all of us have her number. I call her all the time if there’s a resident, a fellow, or a faculty member in need. Called her twice last week. She’s great. She’s really approachable. Obviously confidential, and all that stuff.

So, we talk about it all the time. It’s got to be part of the culture. It’s got to be okay. It can’t be the old sign of weakness if you’re calling the attending or calling the senior residents. So, I think the more that we make it just part of the culture, that’s how our approach has been. And what that does is if a resident sees another resident who’s struggling, just like concussions now are part of our culture and you can… one of the players says, “Hey Doc, you know that 42 is not right.” It’s the exact same concept. We’ve made it part of the norm, not part of the abnormal. And I think that’s the goal.

Dr. Kirschenbaum: That’s superb. Any other comments on that issue?

Dr. Orth: Hey, Ira, this is Charles. A couple of things. As far as our residency and stuff, we have a mentor program with all the other residencies that are associated with us. So, in that form of residents, they can talk amongst themselves and get ideas from other programs, whether it’s internal medicine, general surgery, or trauma, and get ideas from them. The second thing is as a program director and with our residents, we do two things, which other people probably do. We let them do a grit score and we do an activity where we find their strengths with Strength Finders.

And so if I know their strengths and their weaknesses. I as a program director or my faculty can actually try to help them build one or the other if they need it to help them accomplish what is confronting them because it’s unique to them for sure what their stresses are. And we want to be coachable as the faculty. So, I think if we can offer that, that helps too.

Dr. Kirschenbaum: Some other comments?

Dr. Barsoum: I’ll make one comment. So, the first thing I would say is it’s important for you guys to know that your attendings want you to succeed. And the sense that somebody’s out to get me it… just to be clear, it doesn’t look good for a residency program or a fellowship to not graduate the people that started in that program.

So we have every desire to see you succeed and go out into practice and absolutely kick butt. Every one of us has trained department chairs now, journal editors, members of the most prestigious societies, and it gives us all a tremendous amount of pride to see those folks succeed and know that we had a small role in helping them.

The other comment I want to make that is important is, learn from the stress that you’re going through during medical school, during residency, and during the fellowship. Because I will tell you, and I’m curious about what my colleagues on the line here have to say. My most stressful year was my first year in practice, by a lot. And the reason that was my most stressful year is that as a resident and as a fellow, I was stressed about kind of letting my attendings down. But in my first year in practice, I would stress about letting my patients down a lot more. So, I was waking up every morning at 3:00 in the morning thinking, “Oh my gosh, is that wound too red? Is that hip going to dislocate?” And it was just a different world.

So, I want to make sure you kind of recognize that that’s a possibility because when you do feel that stress your first year or two in practice, you shouldn’t feel like it’s abnormal, like you’re the only person feeling it. I think it’s actually quite common. I’m watching folks’ heads nod, but I think that’s probably worth hearing from other folks as well. I mean, hopefully, I wasn’t the only person that felt that way, but it really… it was very real for me.

Dr. Kirschenbaum: Yeah, it’s interesting. I remember coming from my fellowship where the first joint replacement was in the recovery room at 8:15, I thought I’d come out in my first year in practice and start doing 45-minute joint replacements, and then I began to find out what two hours looks like in my first year, just because I’m double, triple checking things and that I didn’t when I was being mentored by Bob Booth, Bill Hozack or Dick Rothman. It’s a very interesting time and very stressful that first year. Really is.

Dr. Levine: It’s the first three years I think are the most intense years of a doctor, surgeon’s life. That learning curve is just intense and you’re at the height of confidence at the end of your fellowship and then the next day you’re like, you look to your left and you look to your right and you’re like, okay, there’s no one else here. Game on.

Dr. Kirschenbaum: Right.

Dr. Plancher: I call it… I teach my fellows, it’s called Fellowship Deceleration injury. And that’s what it is. It’s just like Bill says, you leave and you look at what just happened. And I think it’s actually, Wael, it was really well said. I’ve seen now people start to retire, colleagues. And they sit down and a few of them have gotten so emotional afterward because they didn’t realize they had that monkey on their back for all these years of worrying about their patients every day.

So I don’t even know if it’s one year or three years. It might be 25 years and that’s the disease that we live with, but I think it’s a great disease to live with that as Bill would say, makes us want to be that outstanding human being to help others.

Dr. Kirschenbaum: We talked about the job part, of the job divorce. What do you look for in the second job? If the first job didn’t work out, do you pick yourself up, go to another part of the country? Do you just take a job in a place where you can get your boards? I mean, what do you think about if the first job doesn’t work out? Because I’ve been interviewing a couple of people whose jobs have not worked out. Kevin, what do you look at?

Dr. Plancher: Well, so my life started in academics right around the corner from you, as you know in the Bronx. Loved it. Came out of Fellowship with a gang of five, Joe Bosco and others. And unfortunately, my chair or it could be a senior partner I think I didn’t ask those questions and didn’t represent, and so after seven years, six years, I don’t remember what it was, I had to find something different. So, what Bill said, is sometimes you can’t find the job that’s there. I chose a very different outside-of-the-box path. I created my own path. So, I understand that’s a very different thing that’s difficult to do today, but I think you have to look for… going back to what Matt and Wael said, it is about culture. And I think I didn’t investigate the culture first.

So, I think in finding that second job, it’s imperative to live it. Maybe you spend a few days in the practice where you’re going to see what it’s like. Maybe they do put their best face on for you, but I think you can find it out. And then you speak to the most junior person, not the most senior person, but the most junior person, and see if they are loving it, and if are they willing for you to join. Because sometimes I think there’s a bad disease in medicine, because I think there are plenty of patients to go around but there’s always this protective thing that there are not enough patients and the most junior person will lose somehow financially. So, I think it’s important to befriend and really ask that junior person, I guess, would be a starting point. I’d love to hear from others.

Dr. Kirschenbaum: Bill?

Dr. Levine: Well, if you want to find out about a job, there are two groups of people to talk to. Kevin’s given you some of the people. Great ideas, and great suggestions. But the two people you want to talk to are your product representatives, the vendors from companies.

They see every surgeon and they see what they do and how they act and how they behave in the operating room like no one else does, as do surgical nurses. Those are the people that can see behind the curtains and we tell people to talk… you have your Arthrex rep, and you’re thinking about a group in Kansas City. They’re going to hook you up with the folks in Kansas City and you can talk to them because those are things and details that you cannot find out from anyone else.

They know the real story. And I think that that’s a big part of the culture that Kevin and others are talking about that you might not have any clue about on how those people behave in the OR. And as a junior person, that can be really enlightening.

Dr. Cannada: Yeah, you brought up a great point. It’s always the behind-the-scenes folks that you need to get the answers from. Everyone talked about the importance from the beginning: culture’s important. Sometimes people choose jobs in the beginning for their reputation and not paying attention to the culture. So that’s what they have to realize, that may be what led to them looking for a second job because they chose a job based on the reputation of who their partners are and what they thought they would get them.

And there are two big things when looking for a job. Which matters more, is it the location or job type? Kevin talked about how he created his own job after being in academics, but with your family, is location going to be more important? And then you have to define what will get you in that market. And also, with looking for a second job, you always learn from your first job. So, what did you learn, and what would you do differently? That’s also some important self-reflection that needs to go into the equation.

Dr. Kirschenbaum: I’m really curious from a number of people here, what business knowledge do you think you need to learn early in your career? What business knowledge do you need to know early in your career? I’ll start with Wael, then I’ll go to Joe and then we’ll move it around.

Dr. Wael Barsoum: I think a lot of that depends on the kind of practice that you’re joining. I spent the first 25 years of my life working for the Cleveland Clinic. It was a salaried model, academic. I didn’t have to worry about billing. I didn’t have to worry about negotiating rates with insurance companies. My knowledge around business came from holding various administrative roles within the organization, but it wasn’t necessary for me to be a successful orthopedic surgeon in that model.

So if you choose to go to a Geisinger, to a Kaiser, to a Cleveland Clinic, to a Mayo Clinic, that’s not going to play really a big role for you. If you’re going to join a big practice, a big private practice, I would make the effort to learn about how is overhead calculated. Is there a sliding scale for reimbursement based on RVUs?

Some practices, for example, the first. 4,000 RVUs you generate a year, you get paid a very small amount per RVU because that’s covering overhead between 4,000 and 7,000 the number goes up between 7,000 and 10,000, the number goes up further, and above 10,000, you might be making $80 per RVU. So, it’s important to understand kind of how that works because that’s how you’re going to get paid.

Understanding ancillaries. How do ancillaries get distributed? Meaning physical therapy, radiology, MRI… is that going to play a role for you in your compensation? Are you expected to write a check to buy into those ancillaries? Is it included in the partnership? So those are all kinds of important things that you need to understand.

So it isn’t so much reading the P&L and understanding the cost of capital and a lot of the things that you might learn in an MBA program. It’s more about understanding the business of that practice. And I think you heard it pretty well in terms of who to talk to. If it is kind of a complex practice with different ways of compensating folks, talk to the junior members of the practice, especially those that just made partner, right? How did you make a partner? Did you have to write a check for that partnership? Does the practice have a “Goodwill buy-in”? Which is now, I mean, less and less common, but some practices do. They say, well, you know, the reputation of the practice is so great, you should pay something towards that. They might not call it goodwill, but they have some other term for it. So those are the, I think, some of the business terms that you really want to understand, and again, the Cleveland Clinic doesn’t have a contract. We would get a one-page letter that said, you are hired for one year. This is your salary. You get the same benefits as everybody else. If you are in, sign below. That was my contract for 25 years. Every year for 25 years I re-signed for that same exact thing.

Again, a different model than going into private practice. And if you are going to go into private practice, I would strongly encourage you to have an employment attorney that understands healthcare law to look at your contract and ensure that there’s nothing that’s going to take you by surprise later. It’s nothing worse than signing a contract that you didn’t understand.

If you understood it and it turned out not to be the right job, that’s okay. That’s on you. But if you didn’t understand it, that’s really kind of a pretty bad outcome.

Dr. Kirschenbaum: Joe?

Dr. Abboud: Yeah, I mean, all great points. I think coming out of residency and fellowship, this can be overwhelming. And so yes, getting an attorney to do some of this work for you is very important. But as you grow into your career and become a better surgeon and provider of care and diagnostics, which is obviously the most important first aspect of being the best professional you can be. You do need to I think go back to school for some of this stuff. Working on how to be the best leader you can be. How to read balance sheets, finance, marketing, all the aspects of becoming… whether you want it or not, you as a resident and fellow, and then young attending become a middle, career attending who sometimes gets thrown into leadership, and you want to have some of the skill sets and tools from people who can educate you on it formally sometimes.

So going back to school is something that I did at an older age and I really enjoyed it because I’d had some time to do some things and have an apprenticeship model of working with somebody. But it wasn’t enough. I needed some more formal surroundings around it to really help me understand things better. And force me to read things and have some tests to take and make sure I understood the content so I could become better at it. Cause all these skill sets to need practice. Just like Kevin was saying in the beginning, they’re all individual skill sets. Surgical skill, bedside manner, knowledge-based research method, writing papers, public speaking, administrative leadership. They don’t come mostly naturally. Very few of us have one of those skills naturally if we’re lucky. So, they all need education and mentorship, and sometimes you need it formally if you don’t have necessarily all the mentors around you that you need.

Dr. Kirschenbaum: Matt Barber?

Dr. Barber: Yeah. I would I wanted to echo that from what Wael said and Joe, and piggyback to what part of what Joe said earlier: how do you get in, how do you get out and how do you get paid? So, figure out what does that track to partnership look like. How do you get back out of it if this doesn’t work? Is there a non-compete involved? How do you get paid while you’re there? What’s the compensation model if you’re in an employed deal with a hospital and it’s RVU based? What’s their ability to disallow RVUs or bundle them in with something else? You really need to understand that and exactly what they said. Like your friend who knows a lawyer and gets them to look over it and say, “Oh yeah, that looks standard. It’s not cool.” Whatever is not in print, it doesn’t exist, and whatever you signed on is what you signed on. So, you need to go through that. Redline it and ask for whatever you wanted, and back even to what Lisa said, this whole process takes a lot of self-reflection. You’re trying to figure out what’s important to you in life personally and professionally. Where you live, the type of practice you’re in, all those affect you and affect your life. But give yourself some grace too, because that’s all going to change and what was a fit for you starting out might not be a fit in 10 years or 15 years.

And just like with the business, we can all strive to understand this, but the business model in healthcare just flips all the time. I mean, you and I talked, I mean, my mentor was in like a four-man group and they had a helicopter. That’s not happening in 2023.

Dr. Kirschenbaum: Right. I get that. I’d like to echo what Joe said about getting an education there. In our department, if the attending’s been there three years, we send any young attending to the Harvard Managing Healthcare Delivery course, which is a nine-month course of three weeks on campus and eight months of offsite learning.

And I’ve already sent six attendings to this course to bring them up to speed as to what the healthcare environment looks like. And the department actually pays for that. I see one of my attendings on here probably taking notes saying, “I didn’t know that.” But we’ll rectify that if you didn’t know it.

Any other comments? What I’d like to do is just go around the horn. I want some closing comments. Maybe include… what makes for a good medical student, what makes for a good resident, what makes for a good fellow, what makes for a good orthopedic surgeon? Just maybe a little summary about that, and I know everyone’s thinking about that question right now.

Dr. Abboud: I would say embracing change because I can tell you that the only constant is change and you have to adapt. Healthcare is obviously, always changing. Your life’s always changing and learning to adapt is really important.

Dr. Kirschenbaum: Great. Lisa?

Dr. Cannada: The tips I have, the three things I’ll say, are whether you’re a medical student into residency, residents into fellows, fellows into a job or moving jobs, to succeed, you must integrate well. You must integrate seamlessly and rapidly. Weave into the fabric of the whole team. And to be great, you must be quietly compulsive. That goes along with Bill’s talking about lifelong learning. And to be great, you must also provide added value. No matter what level you are you could provide added value. You could provide added value to those around you and make your teachers better teachers and clinicians by asking questions and by being prepared. And you want to be an active and thoughtful learner. So, integrate well, be compulsive and provide added value.

Dr. Kirschenbaum: All right. Bill? Final comments?

Dr. Levine: Yeah, I think that the key element that I try to instill in people is to have self-awareness. If you have self-awareness, you can hopefully… when we talk about 360 evaluations, what I tell people is you shouldn’t need a 360 evaluation. You should be able to come into my office or into any of your mentor’s offices and give a 360 and likewise in reverse. And if you don’t have self-awareness, then get a coach to help you, because there’s nothing that’s going to get you into or out of trouble better than if you have that one facet in your lane.

Dr. Kirschenbaum: Awesome. Wael?

Dr. Barsoum: I think you have to remember first and foremost that as doctors, we are given what I would consider the highest honor ever in that patients are literally choosing to put their lives in our hands. And given that, you have to recognize that to some degree, you lose the right to be selfish as a doctor. You’ve got to recognize the value and the honor that people are giving you. So again, getting that call at 2:00 in the morning for a hip fracture and you’re like, well, I’m not going to operate on it tonight. Do I really … Just kind of put the patient to bed, we’ll take care of it. You got to wonder, is that how you’d want your grandparent taken care of, right?

I mean, obviously, you’re probably not going to get up for a straightforward hip fracture in the middle of the night but do everything you can to make sure that patient is comfortable, they’re getting the best care. The attention to detail is extremely, it’s extremely important that you always keep that in mind. I would tell our caregivers at the Cleveland Clinic when I was with Cleveland Clinic, Florida, tell them outside of orthopedics, cause obviously we’re doing a lot of cancer surgery and transplant surgery and whatnot, to tell folks, “Look, there are patients walking through our doors. Literally, this is the worst day of their lives, and you have the opportunity to make it a little bit better. So, recognize that responsibility and that opportunity. Don’t be selfish and think about the patient.”

Dr. Kirschenbaum: Great. We have Matt and then Kevin to finish up.

Dr. Barber: When I was an intern Ira, I think I made like in the 10th percentile on the in-training exam. And my chairman sat me down and was like, “Look man, you got like five years to master orthopedics and to learn everything that you can here. So, get to work.” So, I would say soak it up, just like learn everything you can. And maybe I should have gotten the lesson sooner. I mean, I did obviously as a medical student. But when you’re a med student, resident, or fellow, take that time and learn.

I mean, as everybody said, you’ve got somebody there teaching you and supervising you. The level of care that the faculty here have shown and what they do to try to help their residents and fellows succeed and take care of them is incredible. So, avail yourself of that. Learn everything that you can and just ask a million questions to them, to everybody you’re around. And so that then flows over to where you’re going to do your residency, where you’re going to do your fellowship, to jobs you’re looking at. Just talk to people and keep asking, because you’ll see the common themes, you’ll see what’s standard, what’s not, what fits with you, what’s that cultural fit. And just reach out. I mean, you’ve got right here incredible access. All these surgeons, all these folks are on LinkedIn and social media. A lot of them are accessible and you can reach out and ask questions. So do that.

Dr. Kirschenbaum: Kevin Plancher bring us home.

Dr. Plancher: I’m not going to get too religious, but we were given two ears and one mouth, and therefore don’t let technology control your life. I am going to get up every night for my patients. It’s never about me. I’m going to be old school. It’s about my patient. Rephrasing what Dr. Barsoum said. Do you want to be good? That’s great. You want to be amazing. You’re going to have to give up yourself and it’s going to hurt. And so, you have to share. We deal with human beings.

And therefore as I close it out, I say to my colleagues with their screens that are off, turn on your screens. I want to see your face. I want to know who you are. I’m sorry. I’m going to be the elephant in the room. And so, I can’t wait to meet each of you, that we all share together cause I will only learn from all of you. And I need all of you because I am getting old and that’s it.

Dr. Kirschenbaum: Well, I’d like to just say a couple of final words. Big thank you and great honor to be with this faculty tonight. These are people I look up to on a regular basis. I want to thank everybody and thank the faculty very much.