If I Knew Then What I Know Now


The following are short essays written by past SpineLine 20 Under 40 winners, on advice they would give current residents and fellows. With an overwhelming amount of responsibility on the plate of young physicians, the advice is intended to give residents and fellows some helpful pointers and tips to follow as they near the end of their training.

Samuel Joseph, MD

Learning how to do spinal surgery is just a small part about practicing medicine. There are many challenges that face fellows and residents as they look for the right job, negotiate the right contract, build a practice, and interact with industry.
Learning how to do spinal surgery is just a small part about practicing medicine. There are many challenges that face fellows and residents as they look for the right job, negotiate the right contract, build a practice, and interact with industry. The little exposure we get during our training to address these challenges is not sufficient by any means. Since my days as a fellow in New York City and now having been in practice for 12 years as a private practice spinal surgeon in Tampa, I have learned a lot.

Finding the right job is not easy. That is why around 50% of us leave our initial one. When you begin trying to find a job, I think the most important thing is understanding where you see yourself in 10 years, not 2. As an orthopaedic surgeon you need to decide if want to continue to do general orthopaedics or limit yourself to spine. As a neurosurgeon you need to decide if you want to continue treating brain pathology. During my search for a job, this was the first step. Once that is decided, then you should look to geography, call requirements, as well as potential income and growth. I have learned over the years that if there is something that you do not like about a position, you either need to accept it, or look elsewhere. Change is very difficult.

Once you figured out where you want to go, you need to make sure the contract makes sense to both parties. Obtaining an attorney is very important as the initial step. Something I learned after both accepting contracts and presenting them to incoming surgeons, is that the key is to make sure both sides are committed and have “skin in the game.” A one-sided contract is not ideal for anyone. As a surgeon starting out, you want a practice to be committed to your success and have a financial incentive and risk tied to your performance. I would also caution surgeons to beware of the contracts that offer huge amounts of money. The devil is in the details. These positions tend to have a large amount of downside as well and limited time frame for the money.

When starting to build a practice, the new surgeon must understand that the true work has only just begun. I have learned that you will need to dedicate a great deal of time to building the practice that you want. Time is needed to meet referral sources, other surgeons in area, as well as hospital administrators and patients in the community. I would recommend accepting as many patients with as many problems as you can handle. Being too selective can hurt your practice right off the bat. Accessibility is important. This can be accomplished by giving out your personal number to your referral sources, as well as getting patients into the office in a timely manner. Accepting transfers and building good report with the emergency room is also a part of getting your name around in the community, especially if you provide efficient and good care. As with anything in life, what you put into your practice is what you will get out.

Industry, including spinal instrumentation companies have a role to play in the development of a spine surgeons’ practice. During our residency we are limited to what our attendings used. Expanding your exposure and giving multiple companies a chance to showcase their equipment will allow you to make more informed decisions relating to picking your screw, cage, etc. of choice. Attending cadaver labs and courses can be a valuable tool to refresh your skills and learn new techniques. This can be especially important during the start of your career since you will have the time.

Finding your dream job and building a successful career is difficult, but possible. It starts with providing great care. The rest is being honest with yourself about what makes you happy. Good luck!

Tobias A. Mattei, MD

You have completed your neurosurgery residency, passed your written board and are now finishing your scoliosis and complex spine surgery fellowship. You have already interviewed with several groups and interesting proposals have arisen.
A Primer in Contract Negotiation for Young Spine Surgeons (or, in Simple Words, How to avoid being Cheated on)

You have completed your neurosurgery residency, passed your written board and are now finishing your scoliosis and complex spine surgery fellowship. You have already interviewed with several groups and interesting proposals have arisen. Today, a contract from one of the groups arrived in your mailbox. It contains no less than 30 pages, with plenty of archaic formal terms such as “hitherto”, “henceforth” and “whereof” which, honestly, do little to make things more clear to you. You are so busy to read every single clause and besides that the proposed annual salary seems reasonable and you liked the place. Therefore you just jump straight to the last page, sign, date and mail it back, look-ing forward to the dream life of a highly skilled spine surgeon dealing with complex pa-thologies.

However, a few years later, things do not look so bright anymore. You realize that the overhead of the practice employing you accounts for more than 50% of what you bill. As your six-figure salary puts you in the higher bracket of income tax, the U.S. Treasury takes almost another 50% of the remaining. State incomes and property taxes come as a bonus to make you even more miserable. Your call schedule is very busy and now that the family is growing you would like to devote some precious time to them. You think about leaving the practice and joining another group across town about which you heard good things. Before, any impassined decision, you decide, just in case, to read again (now carefully) the contract you signed a few years ago, just to realize that the agreed-upon terms are not exactly in your favor. You have agreed upon a “non-competing clause” which prevents you from working in a 20 miles radius from your cur-rent practice location. You check on GoogleMaps and such a carefully chosen number simply covers every single hospital in town. At this point, the option is either staying in your current exploitative practice or trying to convince your spouse, who is probably busier than you are managing three little ones who joined the family in the past few years, that it is your best common interest to pack everything, leave the friends and meaningful relationships you have just established in the local community to, once again, face, a brave new world. By the time you give your resignation notice, you realize that the billing practices of your employer and their convoluted math was far from ko-sher. You think about vindicating your rights and seek legal counsel. Only to discover that, again, in your initial contract, you have agreed upon an arbitration clause which prevents you form seeking legal remedies in court, while demanding any dispute to be resolved in arbitration. You hear that the arbitration provider selected by your employer (lo and behold) is quite “business-friendly”, perhaps something related to the fact that your employer is the one who regularly pays the arbitration fees and, as expected, no well-respected private resolution entity willfully disregard the interests of their long-term, faithful client, a classic proverbial goose of the golden eggs.

Such a short nightmare, which hopefully, none of the SpineLine readers has ever experienced highlights some key aspects of contract law which may pass unbeknown to healthcare practitioners. A few simple things to remember when evaluating a contract are: “every word matters”; the drafter of the contract has an inherent advantage over you because of their experience and available legal counsel; now innocuous and apparently inapplicable clauses may one day cost you dearly and, more than anything, if you have that intuitive feeling that something is not fair, you better pay attention because it is probably true. Remember, you are a valuable asset! You can negotiate your terms and, based on your excellent academic qualifications and training, there will be plenty of po-tential parties interested in your specialized services. Don’t be afraid to request it your way, to demand a compromise or, if everything fails, to simply say “Thank you very much but I believe it won’t work for me”. Worst than being unemployed for a few addi-tional months is to be stuck in a poor employment for years, bound by legal commit-ments which you yourself in a glimpse of poor judgement and anxiety promptly agreed in order to finally start your carreer. Be patient and meticulous, read carefully and, if necessary, spend a few hundred dollars seeking legal advice. Remember that where and under which conditions you will work is one of the most important decisions of your life, the culmination of years of hard labor, and, therefore, deserves the due diligence. I promise you it will ultimately pay out. Advice from someone who has been through some of the aforementioned hardships but who now has the privilege of providing some guidance so that the bright and young generation may avoid the same mistakes. As Otto von Bismark, the mastermind of 19th century German unification once stated “Only a fool learns f from his own mistakes. The wise man learns from the mistakes of others’. I hope my own mistakes help you to prosper without having to repeat them. My best wishes, success and remember to study well (as you have always done) for this unique task. [1]

1. Menger R, Esfahani DR, Heary R, Ziu M, Mazzola CA, LeFever D, Origitano T, Barnes T, Cozzens J, Taylor S. Contract Negotiation for Neurosurgeons: A Practical Guide. Neurosurgery. 2020 Sep 15;87(4):614-619. doi: 10.1093/neuros/nyaa042. PMID: 32310279.

Jared Ament, MD

I wish I knew then the magnitude of the responsibility our Attendings had for our training; I wish I knew then the enormity of the risk our Attendings took each time we were in the OR;
I wish I knew then the magnitude of the responsibility our Attendings had for our training;

I wish I knew then the enormity of the risk our Attendings took each time we were in the OR;

I wish I knew then the boundless knowledge I could have still learned while in residency and fellowship;

I wish I knew then how complications can haunt you beyond the chastisement of faculty;

I wish I knew then that mistakes are inevitable; awful but certain, and when they happen, what matters most is how I respond to them;

I wish I knew then how much more I had to learn, even while in practice;

I wish I knew then the different dynamics and opportunities for different practice paradigms;

I wish I knew then how deleterious a bad partnership could be;

I wish I knew then how liberating a healthy partnership could be;

I wish I knew then how “ok” it would feel to ask for help when it was needed;

I wish I knew then how badly the insurance system has failed practitioners and patients alike;

I wish I knew then how little our service, commitment, sacrifice, and dedication matters to some;

I wish I knew then how much our service, commitment, sacrifice, and dedication matters to others;

I wish I knew then how much the practice of neurosurgery was not about actual neurosurgery;

I wish I knew then how grateful I would be to many of the people I resented the most;

I wish I knew then how scary being in practice can be;

I wish I knew then how nonsensical the medicolegal world actually was;

I wish I knew then how grateful I would be;

I wish I knew then how it wasn’t all about me;


Richard Menger, MD

BThe best advice is to talk less, smile more … and listen. Many young academic surgeons come out of top fellowships in systems that are capable of handling the most complex cases with efficiency and excellence.
The best advice is to talk less, smile more … and listen. Many young academic surgeons come out of top fellowships in systems that are capable of handling the most complex cases with efficiency and excellence. It takes time to develop that system and polish that skillset. It requires much more than just you. A spine surgeon can do a vertebral column resection with technical perfection but if the clinic, operating room, neuromonitoring, intensive care unit, floor, physical therapy outlook, clinical follow up, and patient education is not optimized then outcomes will fall short of expectation.

You need to be a leader that maximizes everyone’s potential around you or you won’t maximize your own potential. You have to treat people like human beings and valuable members of the team because without them you cannot function. Listen to what they have to say and integrate the changes you can. It will provide better care and make you a better surgeon.

There are many people who have come before you that have allowed you to stand on their shoulders. There should be a great deal of deference to that. Their advice is so valuable. They have walked the walk. There is no substitute for practicing 10, 20 or even 30 years. Learning from the mistakes of other people and being honest about failure is incredibly necessary. This includes operative mistakes, systems issues, and even tactical and strategic issues.

“I wanted to understand how people outside of medicine thought, acted, interpreted, planned, and otherwise controlled the delivery of medicine,” he says. “To that effect, the year completely shifted my once siloed perspective on delivering surgical care.”

Creating that culture early both in yourself and those around you is important. Listen to the advice of other people and again be brutally honest with yourself. If you rationalize failure or complications, you give them power as you shield yourself from your responsibility and your learning moment. This is how you get to the next level. It’s a culture that needs to be created and nurtured. Failure needs to be discussed, not stigmatized. It’s what separates aviation from medicine. On a more pragmatic level, when there is a complication or a failure most people around you know it, and they realize it, and you will gain their respect by assertively and appropriately owning it. You are the captain of the ship.

At our institution, we set up a dedicated spine team. Certain complex surgeries are relatively new to our hospital. When I started I tried to provide direct attending sign out to the floor nurses for each patient they were about to receive. I personally couldn’t keep that up. It also pulled nurses from the floor. It didn’t add anything specific to care. Bluntly, it just wasn’t a good idea. This was a failure in tactics so we adapted and pivoted and we stopped doing it. We communicate directly in-person to the ICU team. We now communicate directly in other ways to the floor team. Saying it was a bad idea and owning that was important part of that process. We failed forward.

The absolute same holds true for intraoperative complications. It’s not just “bad bone” or a “bad fracture.” It’s more than just a closed loop.

The two best books in this space are Extreme Ownership by Jacko Willink and Leif Babin and Black Box Thinking by Matthew Syed.