The transition from a neurosurgery resident to a staff neurosurgeon involves several challenges. These include the selection of a new employer, negotiation of employment terms, assumption of much greater professional responsibility, completion of the ABNS certification process and relocation with the management of family concerns. One of the more pleasant aspects of the transition is the fact that the income derived from a neurosurgical practice in virtually any setting is far more than a resident’s salary, and the newly minted neurosurgeon is now faced with the enviable dilemma of deciding what to do with this new income. As crazy at it seems, screwing this last issue up is not that uncommon amongst young neurosurgeons, and I have seen numerous examples of poor decision making early in a career having substantial negative consequences down the road. The purpose of this article is to describe common pitfalls that I have seen and provide tips to avoid them. This list is anecdotal and by no means comprehensive. Importantly, I am not a qualified financial adviser, and all statements should be regarded simply as my observations as a senior faculty member, program director, ABNS past secretary and mentor.
Mistake #1: Chasing the Money
This may sound silly, but money should be the lowest priority on the list when selecting a job. If a job is paying substantially more than others, there is almost certainly a very good reason for that. Some positions, in particular, hospital employed positions, can put junior staff in difficult situations with unreasonable RVU targets, penalties for not reaching those targets and a lack of local mentorship and backup. Many “signing bonuses” are in fact predatory loans which may restrict the ability of a young neurosurgeon to leave a bad situation. Non-compete clauses, geographic restrictions of practice and a hostile local environment can poison a promising career. Factors such as family setting, the availability of local mentorship, a fair and transparent business model and a co-operative local neurosurgical environment are much more important than early income guarantees.
Staying in this vein, I am all in favor of neurosurgeons being very well paid for the work they do. We provide invaluable services to our patients and provide substantial revenue to our host institutions. That said, doing marginal or excessive procedures to generate income is not acceptable. Unrealistic RVU targets, some revenue sharing arrangements and poor mentorship can create perverse incentives for such behavior. While abhorrent in any practice setting, the junior neurosurgeon is at particular risk for career limiting consequences given that his/her practice will be much more closely scrutinized by the local community as well as the ABNS.
Mistake #2: Not Taking Care of Basic Business
The continued employment of any neurosurgeon in any reputable practice situation depends upon the attainment and maintenance of ABNS certification. Attaining ABNS certification requires the submission of a case log and passage of the oral examination (which is partially based on the case log). There is a time limit within which this certification can be obtained, and exceeding the time limit results in the inability to present oneself as either board certified of board eligible. In most cases, this will result in termination of employment. It can take a year or two (or three) to get an adequate case log together. Get started early and do not delegate this responsibility to anyone else. A sloppy submission maybe rejected outright requiring a whole new dataset prior to permission to sit for the oral exam. If you are moving between jobs, you need to figure out how to maintain your log across health systems. Recall that about 1/6 young neurosurgeons fail the oral examination every session. You may retake the exam up to three times, but the exam is only offered every six months and if the next session is full, it may be a year until you can re-examine. Take care of business and get this done early and professionally.
Mistake #3: Being an Idiot
Coming out of residency you are relatively young and have not yet acquired the expenses of middle age. You are probably not yet paying college tuition, you are hopefully not divorced, and you are not yet weighed down with the consequences of previous questionable purchases. Don’t rush into avoidable expenses. You do not need an airplane, nor do you need a $150,000 sports car. Your priorities should be as follows: 1. Pay your taxes. Seriously, don’t screw around. Get a good accountant (you will find that things get much more complicated very fast) and adhere to the letter of the law. 2. Pay off your debts. Even with relatively low interest rates, you are still paying money for nothing. Be aggressive at this now, buy a comfortable home and live well but don’t look for the “forever” or “dream” home now. Use whatever largess to pay off the highest interest loan you have and then move on to the next one. You should never carry over a balance on a credit card, you may not have had a choice in the past but now you do. Don’t throw money away. Once your debts are paid, you will be in a substantially better position to move on to that dream home. 3. Invest wisely. Get going on a retirement plan, use tax deferred or tax-free funds to save for child education expenses and avail yourself of any employer sponsored programs. Time in the market is your friend. You still don’t need a plane.
I hope these tidbits are helpful, again take them with a grain of salt and best of luck starting out in the best career in the world!
