AANS Neurosurgeon | Volume 29, Number 1, 2020


Neurosurgery: My Greener Grass

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After seven years of residency and one to two years of fellowship, it is not uncommon for trainees embarking upon their first job to wonder whether the grass is greener in another pasture. Having friends from high school or college who have pursued careers in finance may raise serious doubts as to career choice, especially as medical school and undergraduate loans come due. When these friends boast about generous bonuses or exorbitant salaries, it is only human to have doubts about whether our long and arduous training was the right decision. As we look for our first job, (employed, private practice or academic group), many fiduciary issues confront us, including:

  • Monetary metrics for productivity,
  • RVU expectations,
  • Overhead costs and
  • Malpractice premiums.

Some of us want to believe that medicine should be devoid of considerations of remuneration and financial incentives, but in the world in which we live productivity is ultimately linked directly to our compensation. The newly-minted neurosurgeon cannot help but think about finances. Thus, recently graduated neurosurgeons may find themselves wondering at the balance of service and money, leading to questioning “Is this the career path for me?”

For me, personally, this question fueled my desire to spend time in business first. I briefly worked in business development for a large medical device maker. I also worked at a middle market investment bank, in their medical technology division, managing mergers and acquisitions. I am happy to say that these experiences strengthened my passion and commitment to pursue medicine, neurosurgery in particular.

While working as a banking associate, I realized that I spent many hours working on behalf of our clients, who were either acquisition targets or acquirers. My job was developing business proposals, overseeing financial modeling and meeting with multiple potential clients. The hours were long with routine night and weekend obligations. I realized during one of these late nights, while researching a potential market opportunity for a device or constructing a financial projection for a potential acquisition, this work did not bring as much meaning as performing emergent surgery to save someone’s life or restore movement. The hours were equally long, but the meaning derived was not the same.

Another interesting parallel between finance and medicine is the rigid hierarchical structure.  Within finance, managing partners wield the most clout, while principals, vice-presidents, associates and analysts comprise the rungs beneath. Similarly, in neurosurgery the top is an attending, with chief residents, senior residents and junior residents working below.  In both systems inter-personal conflicts with leadership and within the hierarchy can make for a difficult experience. While training in neurosurgery, we may disagree with decision-making, the care trajectory and whether or not to intervene. This is by no means unique to either discipline, but within hierarchies, having synergistic and collegial work relationships is important.

The seemingly disproportionate compensation also seems unfair to many in medicine. A 14-hour complex tumor resection, which is physically taxing for the neurosurgeon and requires tremendous precision and skill to avoid leaving the patient with impairment, seems grossly undervalued by the current reimbursement structure. It is not merely the hours spent in one operation, it is the prior years of devotion to training, surgery, the cadaver lab and dissection that occur to learn the art of performing such intricate surgery. It is also the availability of the skilled neurosurgeon who often performs this tremendously valuable service for the patient in their time of greatest need. This, contrasted with bonuses and salaries for moving money around, may fuel angst and frustration. 

Beyond these challenges, there is also the physical rigor of operating. There are many surgeons who have carpal tunnel due to repetitive hand motions during surgery and others who have developed neck and back problems from peering into a surgical incision. Despite many safety precautions, there are also hazards associated with exposure to radiation and blood-borne infections.

Those in finance may point to the considerable travel obligation required. Whether it is traveling to client locations for weeks or months at a time, or making frequent trips to meet with potential clients, there is a travel obligation which takes the individual from the home and create family disruptions. However, call obligations may also take the neurosurgeon away from his or her family, and it depends on the individual whether call or travel is more or less disruptive. There are also many neurosurgeons who travel for research or academic commitments – this cannot be overlooked.

Ultimately, whether to prioritize service to others or financial remuneration is a personal choice driven by one’s passions and, in part, financial position. For me, the decision to pursue medicine, neurosurgery in particular, is bolstered by having seen the “other pasture.” I noted that while there certainly are several “pros,” the opportunity to help someone when they need it most and save a life is truly a gift. As a profession, we have the opportunity to make meaningful differences in the lives of patients and their families every day. Our patients turn to us to provide needed advice and our emergent intervention can mean the difference between life and death for a patient, who in turn, has loved ones who depend upon these critical actions. What a privileged position we have for service!



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