Congratulations on finishing your first couple years in practice. What has been the most Difficult part of the transition from residency / fellowship to practice?
Millonig: Transitioning to practice brings in many new challenges that are equally exciting and at times terrifying. The most challenging component for me personally has been the transition to billing in a private practice setting compared to where most of my training existed which was in hospital systems. Additionally, the transition to being completely solo in the OR with a new team can be challenging, it is a different dynamic in large academic centers with access to extra hands for complicated cases even for simple things like positioning an external fixator. It is a totally new dynamic to be without a second set of knowledgeable hands assisting you for outcomes and efficiency.
Ford: I expected the most difficult part of the transition to be getting used to operating completely independently. I have found that refining my indications on the clinic side has been the most intellectually challenging part of the transition. From a workflow standpoint, I have also had to get used to seeing more patients in clinic on a weekly basis than I ever did in training
Clements: Those are all great points. We, as program directors, struggle with finding the balance between autonomy and supervision. Newer oversight requirements by the hospitals have made it even more challenging. I think one of the best parts of entering practice is not having a set of extra hands. In retrospect, this will be one of the most memorable growth moments of your career.
Cooper: I can think back to 13 years ago, coming out of fellowship and looking for those other people in the OR. I think it is a great reminder to everyone in education that we need to prepare our residents and fellows for that, because the reality is that most people will not have a skilled set of extra hands in the OR, at least at first.
Hofbauer: I believe that we all have similar fears when we first start in practice. I think the key is to be confident but not cocky. Start out doing what you do best and progress to more complicated cases. Don’t ever be afraid to ask someone for help. Most importantly don’t take on cases that you think that you may not be able to handle. The beautiful part to this challenge is that every day you will grow more and more confident in the operating room by yourself and with time and more experience you will continue to get better and fear less.
How could our training programs better prepare you for this transition?
Millonig: Have your senior residents or fellows perform cases “solo” in their final months. Meaning you don’t assist a lot, but still oversee the case. This would give them the opportunity to transition to that setting and learn how to manipulate throws and positioning when on their own. Ensure that in training residents get exposed to not just practice models, but billing in private practice and hospital models and are educated on the nuances of billing. It is such an important piece of what we do that is a necessary to do our best to understand it.
Hofbauer: Understanding billing has always been a daunting task. I think there are very few of us that are exceptional at it. I think the key is to find a good mentor that can help you through, someone that you can bounce questions off. In the beginning you have more time on your hands to be able to make the effort to learn the billing process. There are wonderful courses that can help you as well. The idea of coding and billing is a dynamic process that is always changing, and I think all of us continue to learn as we go.
Clements: It’s a challenge to balance all these requirements. Every resident has different needs, every Program has a different structure and culture. Unfortunately, those who train at academic learning centers are less likely to Be exposed to billing as those who train in “privademic” models.
Cooper: I think it is a great point that coding/billing is constantly evolving and requires continuing education. It is really difficult to teach that, especially at university type settings, but there are things we can do. Something that may get lost in today’s training is note-writing ability. I really spend time talking to residents and fellows about how to write a good note that will stand up to billing (and medical-legal) issues.
Ford: I am proud of the training I received in residency at Carolinas Medical Center/OrthoCarolina and in fellowship at Baylor with Drs. Brodsky, Reddy, Royer, and Zide. Both programs were appropriately business-minded and prepared me well for a hybrid independent practice/teaching career.
The logistics of starting a practice from scratch, though, are completely different than the well-developed practices we are exposed to in training. I wish I had better understand the importance of a clinic heavy schedule to feed my surgery schedule. As the old saying goes, being affable, accountable, and available goes a long way in helping to start a clinical practice. It takes a long time to establish referral relationships, a patient base, and develop a busy practice to warrant additional clinical assistance from a PA/NP, so patient throughput is key.
How can you fine tune your indications and develop a rapport with a patient base early in practice and have high clinic throughput? Start clinic early, take a short lunch, and work more sessions of clinic to maximize high-volume, high-quality patient interactions. The cases will come. I wish I have known how to do that earlier.
How do you feel the COVID pandemic affected your residency/fellowship experience?
Ford: I do not think it had a major impact. It affected my fellowship case volume a small amount, but I focused on research efforts during early lockdowns instead. Honestly, wearing a mask helped hide my youth early in practice, which may have been to my advantage.
Millonig: I feel fortunate that while my final months of residency were primarily shutdown for no emergency cases, I had such quality training and quantity of cases leading up to it that it didn’t feel impactful. when I started fellowship, they hadn’t don’t surgery for several months, so we had back logs of cases to do, and I gained a ton of experience from those restarting in my early months of fellowship. While it did change the dynamic within the hospitals system and made operating mor difficult, I didn’t feel my surgical training was affected in my regions. Collaboration via online education was a HUGE benefit of the pandemic and was amazing to partake in.
Clements: What stood out to me was how protected foot and ankle surgery is from other orthopedic specialties. Obviously, we lost some volume on the elective side but foot and ankle trauma and diabetic foot needed hospital and surgical care. Everyone who is new in practice should take note of the value providing this service: to both your community and your practice development.
Hofbauer: I think that one of the biggest things we learned during Covid was how important the ancillary staff is to our professional lives. Moving forward in this post Covid era it’s important to remember to treat nurses, assistants, MA’s, support personnel well. So much of our success depends on their efforts.
Now that you have completed your training, what advice would you retrospectively give to yourself as an intern?
Millonig: Ask questions. Ask as many questions as possible before cases on why procedures were selected, why incision approaches are decided or why hardware was chosen, postop what the protocol is and why, what conservative in care in clinic was already failed. “Practice” cases the day before by visualizing what the surgery steps are going to be. Discuss with your attending ahead of time plan A and bailout plans B and C. There is so much to consider in taking care of patients. . . Think about all of it and ask questions!
Hofbauer: One of the issues with any residency training program is the minimum number of cases required for completion of the program. Too often I think residents shoot for hitting the minimum number to allow for graduation from residency as opposed to getting hands-on experience on as many cases as possible. I believe that by continuing to do more and participating in more cases than are required, your confidence and knowledge base increases exponentially. This will help to temper your fears of operating by yourself that first year out in practice.
Ford: Relationships matter more than you know both within and outside of your perceived future subspecialty. Orthopedics is a small community-learn to better take advantage of the relationships you have developed during training. And don’t burn any bridges - it never does you any good in the long run
What recommendations would you make to the ACGME or CPME to address challenges we all face as we start our practices?
Ford: Nationally, surgeons seem to be worried about shrinking autonomy during training. Naturally, some residents and fellows seek out extra cases and extra responsibilities, while others seek more work life-balance. This is simply human nature. I think more transparency during the training process for the residents and fellows with honest feedback on how they are being evaluated and how they are progressing is of utmost importance. Especially with cross training of residents and fellows, it can be hard, but “case leak,” where cases go uncovered or underutilized, must be intentionally addressed and prevented.
Millonig: More free access to billing and coding information and practice management resources. The most difficult piece of medicine in my opinion isn’t medicine, it’s getting paid to practice medicine.
During your job search, did you notice any trends towards or away from private practice, hospital-based employment?
Millonig: There were opportunities in each of the job types, there is more of a current trend towards multi-specialty groups or orthopedic groups. I had several opportunities in private practice and hospital systems and variations in between that came to light so I really think graduating residents or fellows have opportunity for what excited them pending their geographic region.
Clements: While I have a wonderful job in a hospital-based practice, I predict the trend may switch back towards private practice. If labor issues continue, private practice will remerge. Small private groups have more control to hire and compensate employees competitively. Large systems are challenged by scaled wage adjustments.
Cooper: Having done both (started my career in a true private orthopaedic group and part of a university academic program now), I really don’t know where things will head. In a way, the number of truly academic jobs is a little bit limited, but the other “employed” hospital positions are still going to be attractive due to at least perceived security. With re-imbursement only looking to decrease, and wages for everyone except physicians going up, it is scary to take on that responsibility. I don’t think anyone knows right now, but the current model with travelers making multiple times what loyal nurses and staff are making is not sustainable.
Ford: My training biases me towards independent practice. Unfortunately, I do not think hospital systems do a good job of incentivizing high volume, high quality, efficient care in the orthopedic space. I do not know if this will have an impact, long-term, but most of my close friends/colleagues in the foot and ankle subspecialty are working for independent practices or in true academic jobs
Hofbauer: In my 32-year career I have participated in almost all aspects of practice. Private practice, group practice, orthopedic group, hospital owned and now university based. I would say that the answer to this question tends to be somewhat regional. Considering so many of the issues that we have discussed regarding staffing, billing and coding, and meeting practice regulations I think more people are leaning towards large group practices, hospital owned practices, and university settings where the resources are available to be able to deal with some of these challenges. I do believe however that everyone has to decide for themselves what is most important to them and make their decision based on what truly makes them happy.
