After many years of residency, the prospect of getting a job is very exciting. Unfortunately, that excitement can make it difficult to evaluate a potential practice rationally. During residency one learns little about the business side of neurosurgery, and there is no chapter in Greenberg to help you out. Guidance for evaluating job opportunities in both academic and private settings is the subject of this Residents’ Forum.
The first step in looking for a job is to determine what is most important to you and your family. The main factors to consider are the practice’s location, income potential and financial strength, as well as your interest in a subspecialty and research opportunities. Rank these factors in order of importance, but remember that every job requires some compromise. To decide what is negotiable, you must know your priorities.
Location
Location may be of primary importance, particularly if you have a family. Most hospitals, offices and operating rooms look the same, and you will spend most of your time there. Your family, however, will need to deal with jobs elsewhere as well as with schools, new neighbors and friends, and the like. Talk to people who know the area well, and make sure that you spend at least a few days exploring the area on your own to examine commute times, access to shopping and recreation, and other things that are important to your life outside of work.
Income Potential
Of the 800 neurosurgical job openings each year, approximately 5 percent to 10 percent are academic jobs. Of approximately 150 residents graduating each year, about 50 go on to fellowships, research or military positions, leaving 100 residents entering the job market. At an 8-1 ratio of jobs to graduates, the odds favor you heavily. Regardless of your academic interests and research prowess, remember that your income will largely be determined by your clinical activity. Additional training such as an endovascular or spine fellowship will allow you to command a premium salary.
Because it is a job-seeker’s market, academic practices have increased their starting salaries to be more competitive with private practices. However, this relative equality ends after a few years, as private practitioners become partners in their practices. Compensation of private practitioners is on average 20 percent to 50 percent higher than that of their academic counterparts. So if you are considering joining a private practice, ask about the path toward partner status (for example, time frame and board certification), but remember, everything is negotiable. Practices with large assets such as office buildings or surgery centers may require a buy-in — but be wary if the assets are not easily valued.
Academic compensation is frequently tied to rank. Be aware that the salary differential between a full professor and a partner in private practice may be less than anticipated, particularly when you factor in benefits such as travel compensation, insurance benefits and malpractice coverage.
Financial Strength
Most academic practices associated with a medical school are either a department, which indicates more financial responsibility and direct reporting to the dean, or a division of general surgery where financial decisions are made in conjunction with the chair of surgery — though financial independence for divisions of neurosurgery is not uncommon. Obviously, a private practice is completely responsible for its finances. In addition to paying salaries, a practice must pay employee benefits, office rental, supplies, resident expenses and professional liability insurance. Any remaining money may be paid as a bonus or used for practice development.
You should meet with the business manager to evaluate the practice’s financial condition. Let the manager know in advance what you want to learn, so this person can be prepared with the right information. On the income side, look for the amounts billed and collected, as well as income from alternate sources such as pain clinics, ambulatory surgical centers, office building rents and other sources. On the expense side, look at the “dean’s tax,” salaries and overhead. Also, ask if bonuses have been based on case numbers or relative value units and whether teaching and research have been considered. Is there a business plan for increasing income and decreasing expenses? Does the practice have certified coders? Is it looking at alternative revenue sources? Does it have a plan for expansion? Don’t be shy in asking questions — a good practice will have nothing to hide.
Subspecialization
When considering your subspecialty interest, determine what cases you will be expected to do and what you will need to give up. More importantly, make sure the practice’s expectations are not at odds with the financial incentives. For example, there will be very little incentive to give up high-billing cases such as those with spinal instrumentation if the salary and bonus are determined by relative value units. If you are interested in subspecializing, will you be given the opportunity and resources for developing a new practice?
Research
Starting a laboratory requires space, equipment, money, collaborators, a mentor and a lab technician. Meet with the neuroscience chair and other faculty who share your research interests. Determine if resources can be shared and if they are open to collaboration. Ask for a list of faculty members and their research support.
Protected research time, start-up funds and a grace period in which your research will be supported by department funds are critical for the young investigator. Having an experienced mentor (preferably a neurosurgeon who will understand the unique demands on your time) is a common factor for clinician-investigators who become successful.
The Bottom Line
The most important piece of advice before signing with a new practice is to get the specifics in writing. A key corollary is that everything is negotiable. Be open and polite, but do not be afraid to ask the tough questions. In the end, you will be respected for your acumen and attention to detail.
K. Michael Webb, MD, is a spine fellow at Barrow Neurosurgical Associates in Phoenix, Ariz. Lawrence S. Chin, MD, is professor of neurosurgery at the University of Maryland Medical Center in Baltimore.