Deciding on your first job in orthopaedic surgery is no different from selecting a college, a spouse, or even your career. Your decision is based on limited data and really a gut feeling. You may also lack clarity about your vision of what the ideal job would be like. Doing your own analysis will improve your understanding of the important variables of a job and improves the odds of finding the right one. The ultimate goal is to avoid becoming part of the more than 70%–80% of orthopaedic surgeons who change jobs within the first 5 years of practice.1 This article will cover some strategies for your first job search and your future career.
TIMING OF FIRST JOB SEARCH
It is never too early to start looking for a job. Starting this process while you are in the final 2 years of residency is perfectly acceptable, provided you avoid any long-term commitments. It is rare for the graduating orthopaedic surgery resident who is going on to fellowship training not to change his/her concept of the ideal job after the first several months of a fellowship. This is often the first exposure to alternatives that exist in job settings after being in residency. In addition, you may be better able to refine your search and know what you want in a job. The first 6 months of a fellowship are the ideal time to seriously look at the job market. One cautionary note involves the timing of academic jobs: these may only become available in the fall or later unexpectedly and may not be universally publicized.
SURVEYING THE LANDSCAPE: CAST A WIDE NET!
Traditional information about available jobs comes from journal advertisements, head hunters, search firms, job posting boards at meetings, colleagues, and implant representatives. By the time many positions are formally advertised, many positions are almost filled. If you are hearing about the position for the first time from an advertisement, you are probably behind the curve. Nontraditional methods of finding out about job opportunities are also important and include social media, e-mail queries, and letters of introduction to physicians and hospital administrators. If you are really interested in a certain locale or practice, it is acceptable to initiate contact early during residency and provide updates as your career progress. The practice will become familiar with you, and hopefully, develop a relationship. That being said, early contact does not guarantee an opportunity will come to fruition.
WHAT DO YOU LOOK FOR IN A FIRST JOB?
There is a series of questions that you need to ask about your first job. These questions include your personal goals over a 5- to 15-year horizon, geographic preference, practice setting (academics vs. private practice), employer (hospital, practice, university), and whether you need a higher initial salary versus lower initial salary but better long-term growth potential.
It is important to decide in advance on what is essential and what is not essential. For example, if you are set on a certain city or geographic region, you may have to tailor your strategy based on what that particular market looks like. You may have to consider making compromises in the job you accept if your geographic preference is a very competitive market.
An additional consideration is the implications of being an “employed physician.” Although it is clearly a trend in orthopaedic surgery, the overall proportion of “employed physician” positions in orthopaedic surgery is much lower than in the field of cardiology or neurosurgery. If you are an employed physician, there are additional pressures and responsibilities associated with being a “company man” or “company woman.”2
Citizenship, customer service, attitude, and personal behavior are routinely evaluated with “big business” metrics and may be tied to your compensation and long-term employment. If more personal, control of your destiny is important to you, or perhaps you are fundamentally a “free spirit,” becoming an employed physician where your role in the organization will be subject to service line managers and hospital administrators may not be ideal for you.
KNOWING YOUR PERSONAL GOALS
Just the exercise of understanding your personal goals for the next 5–15 years alone is helpful even in the absence of a job search. If your significant other is tied to a certain geographic area, you might need to strongly consider that area as a destination of choice. If your goal is to be part of a highly successful academic department, then understanding this early on will make it easier to target opportunities and to improve your marketability. If your goal is to have a practice which has strong camaraderie, team spirit, and “feels like family,” perhaps you should consider being an entrepreneur and starting a new practice with like-minded individuals or co-residents with whom you enjoy spending time. Overall, knowing your personal goals will give you a better ability to discern among job options.
SEARCHING FOR AN ORTHOPAEDIC PRACTICE
Recruiting physicians is an expensive process. The stakes are high for any organization recruiting physicians.3 Many organizations even hire recruiting firms. Every day a healthcare organization is missing an orthopaedic surgeon is a day of lost revenue.
Preparing for the first interview is important. By the time the interview rolls around, the applicant should know about the organization, and the organization should know about the applicant. The applicant should definitely know geographic information, specialty-specific information, and institutional data.3 Specialty-specific data include an understanding of the local market density of similar subspecialists, an understanding of the competition, various stakeholders in the market, and referral patterns.
CAREER TRANSITION: FROM FELLOWSHIP TO PRACTICE
The concept of milestones now inculcated in residency training programs is a reminder of the career transition from fellowship to practice. There is a need for new knowledge, often nonclinical, and the kind not well-taught in graduate medical education programs. The knowledge base needed has been defined by Satiani as basic accounting, human resources, Stark laws, contract negotiations, marketing, finance, medico-legal knowledge, health/disability/life insurance, anti-kickback regulations, reimbursement issues, coding, revenue cycles, false claims act, and physician–hospital relations.3 This list sounds like a mini-MBA curriculum and has been called “the building blocks necessary to understand the business of a medical practicice.”3
HOW TO MAKE A GOOD FIRST IMPRESSION
Previous issues of this supplement have reviewed what is important to ask for in your first job. However, none have covered the importance of making a good first impression once you get started. We know that more than half of the physicians will change jobs within the first few years. Some of it may be because the job is not what was promised. For others, it may be they burned bridges when they started, making it difficult to recover and be effective.
When you are entering a new environment, the earliest impressions are ones that are remembered by all. Legal advice and expertise is important when negotiating and signing a contract; however, please bear in mind that the communication style and the manner that you (and your team) go about this sets the tone for your relationship with your new colleagues. The negotiation with your future colleagues is not like when you are buying a car where the long-term relationship, and hurt feelings, are not as important.
Imagine finishing your fellowship, being full of ideas, and raring to go. How do you stay confident and eager when, in reality, you are feeling stress and are at the bottom of the hierarchy?
Yes, an orthopaedic trauma surgeon is a valuable part of any practice; but before you start, define your role. If you are entering a practice with other orthopaedic trauma surgeons, how are the cases divided? If you put on a bridging external fixator, is that patient yours or are such patients later divided among the partners for the definitive surgery? Do all distal femur and/or tibial plateau fractures go to the “knee expert”? Are you expected to develop a niche, and then such cases are referred to you the majority of the time? Since most newly minted trauma fellows want to take on pelvic and acetabular surgery, how will you get these coveted referrals?
If you are the “orthopaedic trauma surgeon” for the practice, it would be helpful to review policies and protocols for what cases are expected to be done on call and those set up for the next day. Otherwise, you may find your planned schedule turned topsy–turvy. In addition, since you are the newest member of the practice, are all of the septic joint, diabetic foot consults, and geriatric hip fractures part of your practice? There are many questions which should be answered as you begin your practice. Do not expect everything to be handed to you. You may have to earn the opportunity for those desired cases.
After 6 to 7 years of residency and fellowship, you are now in charge. It is important to make the extra effort. Be the first one in and last to leave. You have the opportunity to build relationships and learn from others. At this time, there may be temptations, which distract you from work such as increased disposable income, perhaps your first big house, and family responsibilities. Realize that no matter where you are, it takes time to build a practice.
The importance of being friendly cannot be over emphasized. Success in practice is often more linked to “affability” than ability. Strong interpersonal skills and even charisma determine your success more than anything else. If you are an introvert, do not be discouraged. Many individuals we assume to be extroverts are compensated introverts. Clearly, adult behavior in this regard can be changed.4 Do a self-assessment, and decide on your personal action plan to improve your ability to be outgoing and friendly, with a “sales” mindset.
Never walk around with a disdainful or scornful look even in frustrating circumstances. Approach all people with whom you come into contact with a friendly face and positive attitude. You cannot undo the bad first impression you make. Everyone will be asking, “How is the new orthopaedic trauma surgeon?” Human nature is such that a bad encounter gets talked about much more than a positive experience. Do not let those bad encounters add up.
- 6. It is not your way or the highway
When beginning a job, you want very much to demonstrate your methods and expertise. That is why they hired you, right? Well, there are multiple strategies to get the same end result. Do not be so obstinate that you can only have a single way of “draping” or a single “instrument” that is necessary for your case. Observe the way others are doing things in the operating room, and incorporate their methods and your needs into practice. Things may have been done a certain way in the 20 years before you coming. You cannot change culture overnight.
- 7. Learning is a lifelong experience
Lifelong learning is something that most residents understand from residency training. Years into practice, there are still tips, tricks, and techniques to be learned. When you first begin, your “bag of tricks” is nowhere near where it will be in 5 or 10 years. Find a mentor and review cases with him or her. It is important to develop your own plan ultimately, but listen to the input of others. Your best solutions to a difficult case may come from a combination of advice from 2 or 3 people. If you take the time to discuss preoperative cases with others, follow through. Review your results with others and be open to necessary criticism.
- 8. Do not hide your mistakes
No one is perfect. If you have a surgical complication or a case that fails, do not hide it. Acknowledge mistakes, follow protocols in reporting any morbidity and be willing to learn from your mistakes. Many orthopaedic trauma patients are known for their noncompliance and multiple morbidities. These factors may contribute to adverse outcomes, but accept responsibility for your complications and your patients' well-being.
- 9. Practice evidenced-based medicine
You are getting your feet wet before your American Board of Orthopaedic Surgery collection period. That is a welcome relief as you sit back and ponder your first year in practice before entering the “dreaded” compilation of cases period. You will be amazed at how much you matured as a clinician even in that short period of time. However, your practice should not change drastically during that time. There should be indications for every case that you do and support for your methods in the literature. Review controversial areas of practice with your senior partners. And do not complain that the “literature is lacking for certain indications.” If you feel that way, do the research and publish it. Prove your methods are valid.
Starting your career as an orthopaedic traumatologist is the pinnacle of your hard work. Making great first impressions will ensure that your hard work pays off in the job market. The right strategy will ensure that you find the right job, and thrive in it for years to come.
- Judd KT, Burns' S, Hand K. Finding a job in an overcrowded market: getting what you want. J Orthop Trauma. 2013;27(suppl 1):S2–S4.
- Siegel J. Finding your first job in academics: interviewing strategies. J Orthop Trauma. 2011;25(suppl 3):S104–S107.
- Osborne AG. Finding your first job in a community hospital. J Orthop Trauma. 2011;25(suppl 3):S108–S110.
- Burns S. How to find a job after your fellowship. J Orthop Trauma. 2012;26(suppl 1):S6–S8.