Keywords
early career - transition - surgical practice
Since the early days of training in the Halsted era, surgical education has evolved
at a rapid pace. In recent times, increasing regulation such as that from the Accreditation
Council for Graduate Medical Education (ACGME) has restricted resident duty hours
greatly. There is concern among governing bodies such as the American Board of Surgery
and the American College of Surgeons (ACS) that residents from general surgery programs
may be inadequately prepared for independent surgery practice at the completion of
training.[1]
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Some of the supporting evidence for the lack of preparedness includes a concern that
index case numbers have declined as work hours have become restricted. A large study
of general surgery residents showed that the total number of operations performed
by residents graduating in 2011 actually increased by 21% compared with residents
graduating in 2005.[4] Though this is encouraging, the proportion of cases considered as index cases by
program directors decreased. Of the major operations considered essential in the Surgical
Council on Resident Education (SCORE) curriculum, 34% of these cases were performed
a median of less than five times.[4] Though these changes in duty hours and decreased numbers of index cases do not necessarily
impact patient safety, many have called for more flexibility in the surgical training
model to maximize the educational value of surgical training.[2]
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When surveyed directly, surgical residents are concerned as well. A study including
more than 4,000 categorical general surgery residents indicated that 27.5% expressed
concerns with being able to perform procedures independently after graduation. Furthermore,
63.8% stated that they will choose a subspecialty fellowship to feel ready to operate
independently.[10] This correlates well with a survey of fellowship program directors in the United
States. Fellowship directors indicated that 21% of fellows arrived unprepared for
the operating room (OR), 38% had a lack of ownership of their patients, 30% could
not perform a laparoscopic cholecystectomy, and 66% were deemed incapable of operating
independently for more than 30 minutes.[3] This discord between residents and program directors deserves further attention.
Lastly, surgical residency and fellowship training may inadequately prepare residents
in understanding the business aspects of medicine. A survey of otolaryngology programs
revealed that only 8% of recent graduates rated their business of medicine training
as excellent.[11] Conversely, 75% of recent graduates rated their business of medicine training as
fair or poor.[11] Similarly, 60% of recent ophthalmology training program graduates indicated that
they were ill prepared to handle the business aspects of practice management.[12] Though data are limited, there is no reason to believe that a different trend exists
in general surgery training.
The sum of these issues has led many to strive to improve general surgery residents'
preparedness for practice. Most notably, the ACS and the ACGME convened in 2012 for
a 1.5-day summit.[13] Key recommendations from this conference included an increased focus on the transition
to practice, interventions during the chief resident year to better prepare residents
for practice, and effective mentorship of junior surgeons as they enter practice.[13] Based on this, the ACS has developed the “Transition to Practice” program to help
assimilate early career surgeons into independent practice.[14] This is a focused program, where residents leaving a general surgery residency can
have a 1-year paid staff appointment at a participating institution with focused mentorship
and education on all aspects of practice management.
The aforementioned collective information is not to discourage young surgeons at the
onset of their practice; rather, it should serve to highlight some of the contemporary
issues of being ready to enter a surgical career. The knowledge, technical skills,
and specialization of surgical techniques are increasing at an astounding pace. The
following sections will serve as some practical advice to navigate the transition
to an exciting and fulfilling surgical career.
Establish your Clinical Expertise
Establish your Clinical Expertise
The first priority to build both one's own confidence and a clinical reputation in
the community is to have outcomes that are nothing short of excellent. As training
paradigms have changed, allowing less autonomy during the training years, many early
career surgeons are faced with handling surgical cases independently for the first
time. This can be made more manageable by planning ahead (reading, studying videos),
anticipating critical steps, informing the operative team of equipment needs in advance,
working with the OR team to develop preference cards, and obtaining any special equipment
in advance. This all goes into developing one's own style, which should be a top priority
early on in practice. This is the time to be proactive. I took detailed notes on the
steps, exposure, and instrumentation that my mentors used. I made sure that my hospital
had all of the correct instrument trays for me and that all preference cards reflected
my needs. Handling these details proactively allows one to focus totally on the task
at hand in the OR. Additionally, focus on how to be the surgeon in charge of the OR.
I have developed different strategies for teaching whether I am with a junior or a
senior resident. This is a time to handle more of the cases yourself if needed. Though
teaching is important, establishing yourself as a clinical expert with excellent outcomes
is perhaps the most important part of a transition to practice.
Work with a Clinical Mentor
Work with a Clinical Mentor
Perhaps the most important asset to the early career surgeon is to have a clinical
mentorship strategy. In some instances, this can come from outside of your institution,
with former mentors. Ideally, this structure would come from within one's current
institution and should cover domains such as surgical skills and judgment, as well
as building a clinical practice and assimilating into the culture of the institution.
Successful mentorship should meet the mutual expectations of both the mentor and the
mentee, and this may include prospective discussion of cases, retrospective feedback
regarding operative performance, and assistance with critical intraoperative decision-making,
when indicated. This mentorship is most often provided by a more senior surgeon in
the department or by a series of mentors such as the senior partners in a division.
In addition to helping with prospective thinking about surgical cases, a mentorship
strategy is critical in aiding the younger surgeon in dealing with complications as
they occur.
Learn the Business Aspects of Surgery
Learn the Business Aspects of Surgery
Though a full discussion of the various models of practice (private, hospital-based,
or academic) is beyond the scope of this article, developing more than a basic understanding
of billing and coding practices early in one's career is essential. Surgeons need
to become as familiar with coding and billing practices as they are with cancer staging
algorithms. While undercoding can lead to lower reimbursement for services, overcoding
can lead to unintended scrutiny and often penalties from agencies such as the Centers
for Medicare & Medicaid Services. Office encounters will require evaluation and management
(E/M) coding. There are specific elements that need to be documented in the medical
record depending on the E/M level chosen. Additionally, “modifier codes” can be used
if a secondary service such as diagnostic anoscopy is performed on the same visit.
Both the E/M code and modifier code need to be associated with a diagnosis. Currently,
the International Classification of Diseases (ICD-10) system is the most common. Since
there are so many ICD-10 codes available, the electronic medical record is often the
best source to find the proper code. This is important as the more detail we can provide
to reflect the complexity of the patient encounter, the more accurately we can bill.
Procedures are billed using current procedural terminology (CPT) codes. It is helpful
to reference a CPT codebook when coding for specific procedures. Additionally, be
as detailed as possible in dictating operative notes, as additional maneuvers such
as splenic flexure mobilization can be coded for. It is important to work closely
with your billers and coders to be sure your operative cases are being billed at the
appropriate level. A good resource for those interested in learning more on this topic
is the ACS. The ACS runs coding and reimbursement workshops, which can be quite helpful
in learning the rules of coding effectively.[15]
Become Board Certified
Another priority of the early career surgeon is to establish one's self as an expert
in their respective field. This involves successfully passing both the general surgery
and the subspecialty board examinations. Though most young surgeons do pass the board
examinations, an alarming trend has emerged with the fail rate for the American Board
of Surgery Certifying examination increasing from 16% in 2006 to 28% in 2012.[5]
[13] This may often be an effect of the early career surgeon being so focused on improving
technical skills, completing a busy fellowship, and developing a clinical practice
that issues such as passing the board examination may become a secondary priority.
In a specialty field such as colon and rectal surgery, an improvement has been seen
recently on the written qualifying examination, with only 4% of candidates failing
in 2017 versus 19% in 2000. However, still, 17% of candidates failed to pass the oral
certifying examination in 2017 (direct communication with the American Board of Colon
and Rectal Surgery). It is important to make an honest assessment of one's own abilities
and develop a focused study plan to pass the boards. Focused medical knowledge can
be improved through a directed study plan, ideally with self-assessment questions
to determine areas of strength and weakness. If self-scouting determines that test-taking
strategies need to be improved, then signing up for an oral board course or practicing
with colleagues and mentors to improve specific test-taking strategies could be beneficial.
In any case, the top priority for the early career surgeon needs to be achieving board
certification. This will not only help with establishing oneself as an expert in their
community but also, in some instances, may be a requirement to achieve academic promotion.
Build a Clinical Practice
Build a Clinical Practice
There is no single recommendation for building a clinical practice, and much of this
will depend heavily on the local culture. It is, however, important to set expectations.
While in residency and fellowship training, there are seemingly endless numbers of
patients who need surgery, and the benefit of being a trainee is a constant supply
of operative cases. The biggest misconception as many surgeons enter practice is of
the types of cases they will be handling at the outset of their career. Unless there
are currently no surgeons at your institution with your particular expertise, most
early career surgeons will find that the highest proportion of cases early on are
the minor bread-and-butter cases. In a colorectal practice, this commonly means seeing
mostly patients with anorectal disorders, bowel incontinence, and screening colonoscopy
procedures at first. Commonly, in transplant surgery, young surgeons handle far more
vascular access cases than solid organ transplants early in their career. This is
an opportunity that should be embraced.
It is said that being “available, affable, and able” are the requirements for building
a referral practice, and this is certainly true. Make every effort to get to know
potential referring doctors, be available at all times to see patients on an urgent
basis, and communicate with your patients and families and especially with your referring
doctors. Over time, your excellent outcomes will show and you will earn more complex
cases a reward for this. Another aspect of building practice involves developing a
symbiotic relationship with other specialties. For example, as a young colorectal
surgeon, though we are trained to perform colonoscopy, it is often very beneficial
to build a trusting relationship with referring gastrointestinal (GI) doctors. A strategy
which continues to reap rewards in my own practice is to perform less colonoscopy
procedures and instead refer these patients to my GI colleagues. This has allowed
them to build trust in my intentions and has led to a robust clinical practice of
malignant and benign colorectal diseases and inflammatory bowel disease. Though differing
strategies will be needed, depending upon the needs of each community, one major adjustment
to make as an early career surgeon is learning how to effectively market oneself and
to build a clinical referral network.
Lastly, marketing can be a great opportunity to bring in new patient referrals. Newly
practicing surgeons are encouraged to keep an up to date profile on networking sites
such as Doximity[16] and Linkedin[17] but also to keep their profiles up to date on patient review sites such as Healthgrades[18] and vitals.com.[18] It is also helpful to give talks in your community, to give grand rounds to other
medical specialties, and, if possible, to appear on television or radio broadcasts
to address educational topics and establish yourself as an expert.
Achieve Academic Success
Achieving a successful academic research career is beyond the scope of this article.
However, it is at least worth mentioning that a goal of early career surgeons should
be to develop their academic reputation, if this is something that is desired as a
career goal. It is now easier than ever to become involved with surgical subspecialty
societies, and this is one of the more rewarding aspects of practice. Though there
are endless numbers of organizations to become involved with, I would suggest focusing
your effort on the one or two that are the most important to you. The American Society
of Colon and Rectal Surgeons is likely the best initial society to focus on as an
early career surgeon; they have a track record of being inclusive to surgeons from
all types of professional practice settings and are always looking for volunteers
to serve. Attend the meetings regularly, network with other physicians at the meeting,
and volunteer to serve the society. This is most commonly through volunteering for
committee service. It is critical to not overextend yourself and take on only what
you can complete. To become more academically recognized, the work done for these
societies has to be your highest quality work and, above all else, you must adhere
to deadlines. Those individuals who continue to show an unwavering dedication to the
mission of these societies will enjoy the benefits of increasingly important academic
opportunities.
Conclusions
In summary, the transition to surgical practice is a time of great excitement and
anxiety alike. By achieving the basic milestones set out previously, one can start
his/her career out on the correct path to a long-term fulfilling endeavor.
