American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Letters of Advice for Starting Your Surgical Practice

The RAS-ACS Associate Fellow Committee collected letters from ACS member surgeons during the month of June to share with those Associate Fellow members who are transitioning into practice. Enjoy these letters packed with wisdom.

Dear New Practitioner:

Starting a first job after training is exciting and terrifying. It takes some time to transition into this new role, and when I began my first job I wrote myself a list of things to remember. Here is an edited version of that list plus a few things added that I wish I had known.

  1. I made a pledge to myself to wear nice clothing to the hospital and clinic. Wearing scrubs was of course more comfortable, but I noticed that in scrubs I could be more easily mistaken for someone other than the surgeon. I felt more confident and knew I looked more professional in my clinic clothing.
  2. Review all cases and imaging myself a couple of days before surgery. I needed to make sure my cases were scheduled with the correct equipment so I could keep information fresh in my mind. You can’t trust residents, referring physicians, or even sometimes your partners to do this for you, as much as you would like to, so always double check everything yourself.
  3. When you first start out, the residents will not want to operate with you and that’s ok. You need to learn how to do the cases yourself before you can let trainees do them.
  4. Keep reading my textbooks and journals. Early practice will be slow and then once it gets going, it can feel frenetic at times. Make sure to keep reading and learning. This helped me solidify all the information I had learned in residency and fellowship. It helped me feel more confident and to fill the “educator role” to challenge and educate residents.
  5. Be professional, kind, and respectful to everyone. Everyone knows who you are before you learn who they are. You don’t know who might send you referrals or help with scheduling last minute cases. If you can smile, be kind, and make an effort to learn peoples’ names and roles, it will benefit you one hundred-fold in the long term.
  6. As the newest surgeon, your block times may not be very good (i.e., late in the day). If you are doing a tough case, don’t let it get scheduled after 12:00 noon. By the time you get to start and get to a challenging part, it may be nearing 5:00 pm and the hospital might be empty of colleagues who could come help.
  7. Do you need to market yourself to build a practice? Act fast on this. Be the three As: available, approachable, and affable. Also get help visiting referring doctors, send letters, and share your information.
  8. The first few years of practice are humbling and intense. You are still learning in a lot of ways. Be sure to touch base with partners or colleagues. Ask for help when you need it or just to bounce ideas off of someone else. Be confident in yourself, and remember… surgery is still a team sport.

Amalia Stefanou, MD, FACS

Dr. Stefanou is the incoming Vice-Chair of the Young Fellows Association of the American College of Surgeons (YFA-ACS).

Dear Younger Jason:

Congratulations on finishing your fellowship and starting your first job as a surgical oncologist. I know you are worried about being out on your own for the first time. Transitioning from training to an attending surgeon means the decisions and outcomes now rest on your shoulders. However, let me assure you that you are not on your own.

First, you have gotten to where you are based on faith. There have been plenty of times in life when you were not sure where you were going to go but your faith led you to where you need to be, and this will continue going forward. There is going to be a time when you will want to make a job change, and it will seem like it is never going to happen, but know that by waiting for the right opportunity you will be much happier.

Second, you are well trained having completed a general surgery residency at the University of Florida and your fellowship at Roswell Park Cancer Institute. You have experiences at both institutions to draw from to serve as a basis for starting out. These experiences have taught you how to learn and adapt to new literature and add new techniques to your portfolio. You are well trained and know how to take care of patients.

Third, you will quickly find mentors who want you to succeed and will help you on your path forward. You will find mentors who will help you with different aspects of care. You will find a mentor of the same specialty. He will help you by being a sounding board for cases, and he will help you get adjusted to practice by doing cases with you as you get started. You will find another mentor who will identify the leader in you, and he will help you get interested in medical staff and medical group leadership and open up opportunities for you to get involved. Later, you will find a mentor who will get you interested in organized medicine and advocacy work, which you will find more rewarding then you think right now.

Fourth, your family will always be there to support you. There are going to be days, nights, and weekends when you will be frustrated about being away from them and working. They will love and support you in everything you do. But always remember how important they are to you. Make sure you take time to be with your family. There are always more tasks and things that can be done at work. However, your kids will only be small once. Do not feel bad about leaving early some days or taking days off to spend time with your family.

Finally, your patients want you to succeed. It is an amazing privilege that patients trust us enough to operate on them. Treat them as you would want your family to be treated, and remember that while you may see several patients a day with cancer, they are living with a new diagnosis they often know very little about. It is your job to treat their cancer, but do it in a way that provides them comfort.

There will be many adjustments when you go from being in training to being an attending. There will be many successes and there will be days when you will wonder why you went into surgery. Always remember you are well trained; your family, patients, and mentors want you to succeed; and your faith has gotten you to this point and will be enough to carry you through the next phase of your career.

Future Jason

Dear New Practitioner:

I am sure at times you thought the end of your residency training would never come. I am also positive that on occasion you felt that the long hours that you have worked, and the multitude of stressors you have endured, especially during M&M conference, might not be worth attaining your ultimate goal! When you matched and matriculated in your program five, six, seven, or more years ago as a PGY-1, it seemed inconceivable that you would be finally finishing your chief resident year, now ready to embark on the process of being a “real surgeon.” But here you are.

Even though the graduation dinner, chief’s roast, and traditional hoopla may not have occurred because of the COVID-19 pandemic, you can at least take solace in the fact that all who love you are very proud of your accomplishments in reaching this milestone in your career. Now you can begin to focus on the issues that you will face in the coming years.

If you are like the vast majority of your graduating colleagues, you are off to begin a fellowship in a specialty that will hopefully give you many years of pleasure and deepen your commitment to your practice, whether it be in the community or academic setting or a blending of both. You probably chose a discipline—colorectal, plastics, vascular, trauma/surgical critical care—because it represents a defined body of knowledge that you can wrap your arms around and could refine your skills, or it may hold promise for a lifestyle that fits you well and serves the needs of your loved ones. If you are in that minority of your graduating cadre who will embark directly on general surgical practice in an urban or rural setting, it will probably be a challenging transition since residency has only begun to prepare you for the experiences and responsibilities that you will face during the next 30 to 40 years of your career.

The work-hour mandates that have protected your time will no longer provide sanctuary. Having finished residency, you will have to deal with the extremely important concept of continuity of care. You will have to negotiate relationships with partners who ostensibly share patient responsibilities with you but may have differing agendas and interpretations of that arrangement. You will have to learn the business aspects of surgery even though the practice environment is transforming, such that most of you won’t run your own office, manage your own billing, or hire your own personnel. You, like most of your fellow graduates, will work for a hospital or, more likely, a giant, merged health care enterprise immediately upon graduation or after your fellowship training. By the way, make sure that you understand some of the arcane concepts of non-compete clauses and restrictive covenants!

Your knowledge base, now broad and deep at the end of your residency, will be honed, especially over the next couple of years, as you prepare for and take the qualifying and certifying examinations of the American Board of Surgery and your surgical sub-specialty boards. Remember that you will have to continually add to this knowledge base, and I implore you to not let your thirst for education become quenched any time soon. Take it from me, the diagnostic strategies and surgical techniques that you may have mastered in the years leading up to 2020 will perhaps be outmoded in the next couple of decades. Also, as you progress in your surgical career, your prowess as a surgeon will constantly be evaluated by your hospital, your professional societies and certifying boards, your patients, various payers, and governmental entities. Please don’t react adversely to these challenges, but embrace the opportunities to highlight your outcomes that, hopefully, will indicate that you indeed are everything that your residency and fellowship director bragged about! I cannot really tell you how your competence will be assessed during your career, since this continues to be a moving target and it seems apparent that none of your wise mentors really has the right answer.

So, what can I tell you, a bright, energetic, newly minted surgeon in your early or mid-30s, that you do not already know?

First. Do not take yourself too seriously. This is a bit of a conundrum since you will have serious responsibilities, but it is important to remember that everyone can be replaced. As Charles de Gaulle said, “The cemetery is full of indispensable people.” The humility of this stance will offer you some shelter from the burdens of the commitments you will make to your patients and from reckoning with your own imperfections.

Second. Be kind to each other and to everyone with whom you come into contact in the hospital setting. This includes your fellow physicians, nurses, residents, administrative personnel, and those very important people who keep the hospital running and clean even though we do not see them every day. Strive to view things from their perspective, and please find the capacity to forgive those who sometimes make mistakes. You will not be perfect every day, and your generosity of spirit will be remembered by those who witness your shortcomings!

Third. Learn to talk to your patients and explore those important issues in their lives that may be more significant than the surgical issues for which they sought your care. Resist the temptation to get so absorbed in the electronic medical record that you marginalize your unique situation that allows you to listen to the many concerns that most people are unwilling to tell anyone, even their closest loved ones. You still need to earn the privilege of being a counselor to your patients every day, and this is not something that is innate but is an art that is perfected over many years.

Fourth. You will be busy in your practice starting now or after you finish your fellowship, but try not to neglect spending time with family or being so intense that you forget the central concerns of life. Organize your time well. This includes setting time aside for journal reading and education, but also making time to spend with your spouse, your children, and others who are important to you and who help you maintain your frame of mind and “aequanimitas”. If you’re lucky enough to have your parents or grandparents around, always remember to give them time and return the love they showed to you over the years as they supported you throughout your education. Use the modern technology that you have at your fingertips to stay in touch frequently with those you love and cherish. Find time to spend with friends. Pick a time that you go out and have a nice meal or get together so you can unwind from the daily activities that you face.

Fifth. Even though you are busy trying to carve out your new practice and make a life for you and your family, always remember the importance of being involved in some medical or surgical organization. Over the years these associations will reward you many fold by allowing you to share your experiences with colleagues and enjoy the wonderful camaraderie that residency engendered.

Sixth. Also, remember the importance of being charitable and try to support those important institutions and philanthropic groups that, along with you, make the world a better place. As you develop strategies to pay off the significant loan debt that you likely have incurred, begin to plan for the day in the future when you will retire. Consider establishing an individual retirement account (IRA) for yourself, a 529 college savings plan for your children’s education, or other financial instruments that will protect you and the ones you love.

In closing, I am really envious of your position and the opportunities that you have ahead of you over the next several decades. Use your time wisely. Make every day count. Try not to fret over all the novel changes and opportunities that the future will bring, especially in health care. Hopefully, after the next few decades have passed, you will take the time to reflect on your experience and have your own words of wisdom to share in a letter to a new generation of graduating surgical residents. I would really love to have a copy!

Finally, my greatest wish for you as you leave the protective environment of your residency is that you not only go out and do well, but more importantly, that you go out and do good!

Frederick L. Greene, MD, FACS