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Kenneth A. Egol, MD


Published 9/1/2012

Life After Fellowship: Pearls and Pitfalls

A roundtable discussion on finding a job that sticks

Last year, James H. Beaty, MD, of the Campbell Clinic, hosted an AAOS Now roundtable on pursuing an orthopaedic fellowship. Now, those residents who pursued fellowships are wrapping them up and may need some advice on getting started, lest they join the 70 percent of graduates who change jobs within the first 5 years of entering practice.

To provide those pearls, William N. Levine, MD, vice chairman of the department of orthopaedic surgery, residency director and fellowship codirector at Columbia University in New York City, assembled a stellar cast of private practice and academic orthopaedic surgeons. Sharing their wit and wisdom are the following:

  • Craig Della Valle, MD, associate professor, Rush University Medical Center, Chicago
  • Kenneth A. Egol, MD, residency program director, professor, and vice chair of education, department of orthopaedic surgery, NYU Langone Medical Center.
  • Leesa M. Galatz, MD, associate professor and program director, shoulder and elbow fellowships, Washington University, St. Louis
  • Michael A. Gleiber, MD, private practice spine surgeon, Jupiter, Fla.
  • Peter Millett, MD, partner, director of shoulder surgery, The Steadman Clinic, Vail, Colo.
  • Dan Riew, MD, Mildred B. Simon Distinguished Professor of Orthopedic Surgery, professor of neurological surgery, Washington University, St. Louis

Craig Della Valle, MD

Leesa M. Galatz, MD


William N. Levine, MD

Dan Riew, MD


Dr. Levine: Would you advise your incoming fellows to try and secure a job before they start the fellowship or wait until you can help advocate on their behalf?

Dr. Della Valle: I would say, unequivocally, don’t sign anything before starting a fellowship. Almost everybody I know changed their ideas about what they wanted during their fellowship. Take your time making that decision.

Dr. Egol: I think it depends. Some people have certain geographic ideas or academic aspirations about where they want to be. If the opportunity and the right situation come along, I don’t see a problem with signing for that “ideal job” before they go on to fellowship. Things can change, but I would never say never, and I would never say always.

Dr. Gleiber: I don’t think there is ever a time that is too early to start looking. If there’s a geographic area that you’re interested in or that you or your significant other have family ties to, it certainly doesn’t hurt to send some CVs out and let your name percolate throughout the community. But I would not sign anything until I’ve learned a little bit more about myself through fellowship and about what type of practice I want.

Dr. Riew: I believe that it’s a good idea to look early. For example, if you want to go into private practice in a particular area, letting the groups there know that you’d be available in a year could encourage them to hold a spot for you.

But if at all possible, don’t sign with a group or university until you’re at least a third of the way through your fellowship. That way, you have a sense of what your skills are, what type of practice you want, and whether you want to go into private practice or academics.

Dr. Galatz: It depends on what you want. If you are offered a great practice opportunity before fellowship and if that is exactly what you want to do, then take the job. If you’re unsure, wait. It is an important decision and you need to feel comfortable with it.

Dr. Levine: People can change dramatically during a fellowship, so time to mature and evolve is valuable. How do you counsel fellows to maximize their opportunities for finding the best job when they finish their fellowship?

Dr. Millett: It depends on the individual—on what’s important to him or her, whether it’s the job, the salary, the location. I think using past fellows as a network and letting people know early is important if location is a priority. Academic jobs frequently come through word of mouth, and we can often make calls or queries at various meetings to find out what jobs might be available.

Dr. Riew: I tell those interested in academic jobs to start looking early but don’t panic if nothing is available in the fall because the best academic jobs usually materialize in the spring. And it’s 99 percent word of mouth.

I tell fellows interested in private practice to choose a location first and find out which group is the most respected in that area, which group has the most satisfied physicians. Find out if anybody has left and why they’ve left. Do research to find the best available job.

Dr. Egol: The advice we give residents is first to select a specialty that suits their needs and then to obtain the best fellowship possible. Our residents often use our alumni network, and those connections are helpful.

The majority of good jobs come through word of mouth, and we’ve been very successful in helping our residents secure those positions. People tend to keep those jobs.

Dr. Della Valle: I think there are fewer opportunities in academia, so if that’s what someone is interested in pursuing, we reach out to places. The private practice side depends on a lot of networking. If we know someone in the area who could find the reputable practices—those that are looking for new partners, not employees—we reach out. Those jobs lead to the most successful long-term relationships.

Dr. Galatz: I think it’s really important to communicate with your family. If your spouse has strong desires or limitations on practice setting or location, that helps focus the search. The next big decision is academics or private or hospital-based practice. I think it’s important to keep an open mind and to talk to a lot of different groups. You may be pleasantly surprised by one opportunity and horribly disillusioned by another.

Dr. Levine: Give me the top two challenges that young fellowship-trained surgeons face as they go into practice after after finishing their fellowship.

Dr. Galatz: That first year is very stressful. Not only are you usually moving to another community, but you are facing an entirely different level of responsibility. It is a year of tremendous learning and significant adjustment.

Dr. Della Valle: In terms of finding the right position, I think it’s looking for a practice that wants a partner, not an employee. I think the second thing that fellows struggle with is establishing a reputation as a specialist.

Dr. Egol: I think the biggest challenge is uncertainty. Who knows what the next 5 years are going to bring with the new healthcare law, the changes that are going to occur, and the way practices will realign? To me, the standards and expectations of both the public and the government are our biggest challenge.

Dr. Gleiber: First is being happy, in the sense of finding a place where, even if the practice fails, you and your family will be able to thrive. Second is the opportunity to flourish and develop professionally as well as surgically, so that you’re not twiddling your thumbs in the office 6 out of the 12 hours you’re at work.

Dr. Riew: I think the very first challenge, without a doubt, is assuming total responsibility for a patient and that can be stressful. When you become the attending, a minor complication can lead to sleepless nights. If a wound infection or deep vein thrombosis develops, you tend to become hypercritical about yourself, even though such complications are often beyond your control. Time pressure can be another source of stress. In the operating room (OR), you are expected to be productive and efficient. But initially, what other surgeons perform in 1 hour, you might take 2 hours to do.

The second challenge is developing a practice. You have to have the three As: availability, affability, and ability. You’ve got to be around and available to anybody and everybody. You’re going out and talking to referring doctors, putting yourself forward as an expert, even though you’re still very green. For you to be able to come up with the optimal treatment every single time is going to be impossible. But if you make the wrong recommendation, you’re going to beat yourself up.

Dr. Millett: I agree that moving from an environment where you’ve been mentored into one where you have to be a leader is a challenge. But it’s also an opportunity, if you can find a mentor or senior partner who will consult with you about tough cases or complications.

Mentors can also help with practice development, practice management, and leadership and managerial skills. Being able to communicate effectively to everyone in the OR or in clinic—to move from the starting point to the finishing point—is key, and learning those skills in the first year or two of practice is challenging.

Kenneth A. Egol, MD
Michael A. Gleiber, MD
Peter Millett, MD

Dr. Levine: Should you always have your own attorney review the contract provided by your potential employer and partner? Do you have any tips on finding the right attorney?

Dr. Della Valle: I think the legal review is important for a worst-case scenario, but it’s who the people are and having faith and trust in them that is really important. I got the name of the attorney who reviewed my contract from one of my future partners. The lawyer actually let me pay him after I started working, which was incredibly generous; it may be something to ask the lawyer.

Dr. Egol: I think it’s very important, and we actually invite a contract lawyer to talk to the residents as part of our practice management seminars. An attorney who specializes in medical contracts is invaluable, especially in a big city where many issues may arise. It’s definitely money well spent and we recommend it to all of our trainees.

Dr. Gleiber: I would never sign a contract with extended or extensive legalese without having an attorney review it—ideally, one who’s well versed in both healthcare and employment law. I found my attorney through the recommendation of a friend. You really want to look at the entrance and the exit strategies, noncompetition clauses, and termination clauses (with and/or without cause).

Dr. Galatz: I agree. Be aware of restrictive covenants, renewal clauses, malpractice coverage and payments, call coverage (not only equal but equitable), space, nursing coverage, and OR time. Make sure you have what you need to be successful.

Dr. Millett: In the initial employment agreement, you want to make sure that you’re protected if you decide to change or it doesn’t work out. When you move to becoming a partner, an attorney’s review of the agreement is essential.

Dr. Levine: What are some of the reasons that your graduates have changed jobs in their first 5 years and what have you learned about the job market through the eyes of your graduates that might apply to current and future fellows?

Dr. Millett: I think that the number one reason for changing jobs is that it wasn’t the right fit— due either to interpersonal or scope of practice issues. Sometimes, however, better opportunities simply arise.

Dr. Riew: In academics, I think people leave often because they don’t want to have the pressure to publish or deal with a bureaucracy. I think the number one reason people leave private practice is the disconnect between their expectations of what they were going to be doing or earning and what actually materialized.

Dr. Gleiber: Newly appointed practice members are under pressure to produce and provide profitability to their new practice. Whatever their salary is, they’re expected to make that back and possibly more in the first year. Many agreements are set up so that new associates will not receive their “bonus” until they have brought in their salary. This can lead to strife with the partners and perhaps delay partnership, particularly when they are coming out of fellowship and are generally very conservative in their surgical treatment indications until they build up their confidence, which can only be gained in time with successful outcomes.

Dr. Galatz: Fortunately, most of my fellows have found situations that lasted. One of the primary reasons people move is that the family is unhappy. The second reason is inability to build a satisfying practice. My advice would be to enjoy the slower time at first because once you get busy, it doesn’t let up. Take time to focus on your patients, prepare for your cases, and deliver high-quality care. Your reputation will build from there.

Dr. Levine: You all have very successful practices, and Gen Xers and Gen Ys (the “millenials”) have a much different perspective on life–work balance. How do you balance family and work successfully to maintain both personal and professional happiness?

Dr. Della Valle: I do think you need to carve out time and just set boundaries. Say that on this day or this time, you’re going to put down whatever you’re doing and spend time with your family. It is important, and I’m not the best at managing it.

Dr. Egol: I don’t know if I’m the right person to ask either. I spent a lot more time working when my kids were very young. But when they were old enough to do things with, I carved out more time for my family. I have protected family and vacation time throughout the year, but as a trauma surgeon, I have late nights, am on call, and have to leave or not attend certain events; that’s been a part of my family’s life.

Dr. Gleiber: I’m still learning to balance work and life. Since I finished my fellowship, I took my first vacation this summer—3 days—and I was in contact with the office an hour each day.

It’s something that I really need to focus on. I try to leave things at the door and be a husband and father when I come home. I do bring work home with me, but as a solo practitioner, I’m on call 24 hours a day—not including when I’m on trauma call at the local hospital.

Dr. Galatz: I like a lot of variety in life. That’s one of the reasons I love being in academics; I have a very interesting practice but am also involved in organizations, writing and editing, and research. Traveling to meetings, being a visiting professor, and presenting courses give me the opportunity to teach as well as to learn from my colleagues.

My family is very important to me, and I am dedicated to my son. Once I come home, I put my phone and computer down from dinner time until he is asleep. I may not spend all day with him, but the time we spend is quality time. I run most mornings before work, ride my horse twice a week, and try to set an example for professional balance for my son. It’s one of the more challenging aspects of life.

Dr. Riew: I used to work long hours and told my wife I would slow down someday. But 5 years ago, our house burned down, and for 4 months, I went home earlier, cut my practice, and spent a lot of time with our children.

It dawned on me then that the only people who will care about you when you’re retired are your family and friends. If you don’t spend time fostering relationships with them, no one will care how famous you used to be or how many patients you operated on or how many papers you wrote.

I changed my life and forced myself to become more efficient. I have dinner with my family at least three nights a week and I rarely go into work on weekends (although I work at home). Because I travel a lot, if my family doesn’t come with me, I try to minimize my time away. I keep in touch with Skype.

Dr. Millett: It’s almost impossible to have true balance. If you’re in private practice and want a successful, busy practice, you have to be available and taking care of patients. You can’t do surgery on a part-time basis. If you’re in an academic practice, you have to sacrifice some of your personal time to meet academic requirements.

So, I think it’s really hard to find a true balance. I don’t have a good solution, unless there’s a way to get 8 days in a week or 40 hours in a day. But it is all rewarding nonetheless.

Dr. Levine: I think that Dr. Riew has hit on something here. You sometimes come to a point where you say, “What is really important?” and figure out how to get that. But, it is a challenge, whether you’re in private practice, academics, or a hospital employee. Before we sign off, anything you’d like to share?

Dr. Della Valle: I would say that fellows put a lot of time into training and shouldn’t feel pressured to make a decision. Good candidates will have good opportunities. Take your time and think things out.

Dr. Egol: I tell all of our residents not to worry or think about a job based on the amount of money offered. It’s about the people, the situation, and the opportunity for growth. The money and the financial reward will come with quality performance.

Dr. Gleiber: I echo those sentiments. Starting salary is really nothing compared to where you’re going to be in the long term. I recommend trying to picture yourself where you’re going to be happiest in 7 or 10 years. Where will your family be happiest? Where do you fit into the community?

Weigh those factors and what’s important to you. Give yourself time to develop a mature practice, which at a minimum takes about 5 years. Developing a reputation is easy if you are, as Dr. Riew said, available, affable, and able. Operate on solid indications rather than on questionable indications. Not only will that help you pass board exams, but it will help you in the long term.

Dr. Riew: Do everything that you can to become the kind of junior partner that you yourself would want to hire when you become a senior partner. Work hard, be an available, affable, and able person, and treat people around you nicely. It’s not a matter of what this practice can do for you, but what you can do to make yourself an invaluable member of the team. If you do that, you’ll increase your job security, people will like working with you, and things will go more smoothly for you.

Dr. Millett: I tell the fellows they will face a lot of challenges and distractions in the first few years of practice, but if they remember to do their best, they’ll be successful. Don’t look at what other people are doing or what the other surgeons’ OR schedules look like; just focus on providing the absolute best care to the patient who is in front of you and everything else will work itself out.

How you deal with adversity is really critical and says a lot about your character. In the long run, perseverance will also be one of the most important predictors of one’s success.