Abstract
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There are nuances to consider with these two seemingly simple questions. An academic practice has to suit your skills and talents. The desire to enter an academic surgical practice has to be aligned with the school's missions, which generally covers the three core mandates of education, research, and patient care. In addition to patient care, will the candidate be able to embrace one additional mission? If patient care is the only drive for your career, an academic surgical practice may not be the best career choice because the other demands required by the institution (teaching, lectures, skills laboratories, mock oral examinations, and ceding portions of the operation to the trainees) will require effort and time that you are not prepared to give. An overused and disappointing response we hear for pursuers of academic surgery is, “I like to be in a teaching environment,” “A place with residents,” or “I enjoy working with residents.” In academic surgery, teaching is expected. A disingenuous response or hint that you want residents covering your patients at night will readily become obvious.
If one is truly a teacher, a track record of awards, commendations, or curriculum development will help demonstrate that skill. If you are research oriented, some academic output in the recent past is the only credible indicator. Saying “I want to do research” is not enough without a plan and specific aim. It is obvious that funded or mentored research can really only happen in academia, but these opportunities are limited given current constraints. Some memorable answers to “what do you want to do with your career?” have included “I want to be the most famous trauma surgeon in 5 years and this place provides that opportunity.” “My work in quality can only happen in a place like this because Dr. X is here.” “I want to build an esophageal surgery practice that builds on the strong tradition of thoracic surgery here.” These answers show conviction toward a goal and likely alignment with the institution's goals. Answers like these demonstrate understanding of the resources and needs of the school and belief that you can be a fit as a new surgeon. Even if an institution initiates the recruitment based on a specific need it has or skill set you possess, it is still important for you to convey your desire to be aligned with the institution's goals.
A community practice comes in multiple forms. Small practices may be challenging to sustain in major cities but may succeed in rural communities, or if the surgeon meets a particular population's needs (e.g., an Asian surgeon in a predominantly Asian immigrant community, or a surgeon returning to his or her home town). However, these small practices need the support and protection of the hospital, especially for high-expense items such as electronic medical records, marketing, staff, and malpractice premiums. Community practices that are organized multispecialty groups tend to do well, but the terms for practice may often be prescribed by management, which some surgeons find difficult to tolerate. In community practices, mutual “fit” is probably the most essential consideration. More than financial and call arrangements, are there common community bonds? Will a new entrant into the group change dynamics with office staff and hospital administration? Are there enough cases in the community to keep a new surgeon busy so that financial strains will not come between the new partners? What is the history of previous hires and how long did they stay with the group? What do people directly and indirectly involved with the practice say about its reputation and the reputation of the group? What are instances when the group met adversity and how they overcame it? Who has the dominant personality in the group? These are only some of the issues that require a job seeker to do deep dives. Every practice wants to know two things: can the new hire operate and take care of patients and how willing is he or she to work hard for the good of the group (i.e., beyond the obligatory call schedule)?
There are general considerations that a surgeon needs to remember. Unless your very unique skills have an appropriate market demand in the area, and there is a steady flow of patients, it is better to broaden your scope of practice. At one time in the not so distant past, a surgeon could practice bariatric surgery exclusively. But insurance mandates and center of excellence policies often direct patient access, making the surgeon dependent on forces often out of his or her control to have patients. Furthermore, the demand for surgeons exclusively for bariatric practices is not growing given the available number of surgeons with these skills graduating every year. Lastly, bariatric surgery alone may be gratifying for a time period, but surgeons often appreciate variety and want to operate on colon tumors and thyroid masses. In this author's opinion, a surgeon with bariatric skills should seek to maintain his or her skills in general and gastrointestinal surgery to broaden professional offerings, and never be cornered into a limited scope of practice—especially early on in the career.
There are commonalities between academic and community practice that are worth mentioning.
1. Mentoring: Find a mentor before you even start. Everyone, in academic or private practice, should identify a mentor who can give career guidance, scrub into the operating room to help out, and be the research mentor for the academic components. Mentoring, whether explicit or implied, is the most important component for a successful career trajectory.
2. Clinical excellence: As professionals, we are judged by many standards—depending on what role you are assuming on a given day. As clinicians, your early clinical performance will always be your initial brand and currency for credibility.
3. Word of mouth: Positions are often filled because someone made a connection between two parties with mutual needs. Furthermore, word of mouth by nature offers additional insight into the candidate and of the practice. The referrer can often sway a decision to interview or not. It is therefore important for the candidate to manage and guard his or her reputation years before the actual job search begins.
4. Curriculum vitae hygiene: Keep your curriculum vitae (CV) updated. Line items that cannot be verified should be redacted. Even innocent oversights can seem like deception or carelessness; both traits are bad. Have someone more senior look over your CV and ask whether it tells enough about your career timeline.
5. Send a video: If you are a surgeon, having a video ready for presentation that represents your abilities can often be a nice differentiator among a stack of two-dimensional CVs. It conveys to the viewer your abilities, even if it is a well done cholecystectomy.
Where do you want to live? Cost of living, schooling for children, ease of commute, opportunities for the spouse, comfort in the community, and family and social support structure all inform your choice of location. I used a web-based cost of living comparator when considering jobs in two large sized cities to figure out how far my money would stretch. Choosing a place without connections or convincing yourself that the family can tough-it-out, even if the salary is high, has attendant risks. The cost of uprooting and searching another practice can set you back financially and disrupt the family routine. The time expended in one location is opportunity lost to build a practice elsewhere. In some instances, the suitable place to live may have to trump a lucrative salary.
Clearly, the advice offered here is not about the technical details of job searches. There are available resources constructed to give advice about negotiations and checklists. The one that comes to mind is the Society for the Surgery of the Alimentary Tract (http://ssat.com/residents/residents-archive/#a20). The most important determinants of a successful early career will always be the clarity of your aspirations, the fit with the organization, and the availability of mentors. Having these is priceless and will help you give better care to your patients.