Listen up, residents and fellows: 12 spine surgeons' advice for the next generation


The next generation of spine surgeons graduating residency and fellowship programs will soon be making many important decisions, including choosing their career path, the surgical skills and techniques they wish to hone, and where and with whom they wish to work. There are many challenges, but also many exciting opportunities. 

With this in mind, 12 spine leaders look back on their careers and share their best advice for emerging spine surgeons.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.

Next week's question: What will artificial intelligence and machine learning look like in spine surgery in 10 years?

Please send responses to Alan Condon at by 5 p.m. CDT Wednesday, Nov. 9

Editor's note: Responses were lightly edited for clarity and length.

Question: What advice do you have for spine surgeons graduating from residencies and fellowships next year?

Alex Vaccaro, MD, PhD. Rothman Orthopaedics (Philadelphia): To the graduating residents, if you have chosen to pursue fellowship training, congratulations on your match and begin to determine whether you would envision practicing in an academic or a private setting. If academics is in your future, identify research mentors early and consider feasible projects that

you can complete within the academic year, as most fellowships are only one year long and it will be difficult to create prospective projects or build data sets with your limited time while being busy with clinical duties and training in fellowship. Continue to engage in academic activities such as presenting at research conferences or joining educational committees. If you are interested in private practice, think about the types of procedures you would like your future practice to encompass and focus on maximizing efficiency and repetition in these areas to gain as much exposure and comfort as possible. In both academics and private practice, focus on networking with others in your field as job opportunities after fellowship (as well as your future professional relationships) begin to develop during this time.

For the graduating fellows, do not underestimate the importance of the clinic. While many fellows head into fellowship with the mindset that they should maximize every opportunity to be in the operating room, it is in clinic where you hone your examination skills and decision-making important for surgical indications, cultivate patient-physician relationships and gain experience in practice management. In addition, your goal as a fellow is to be prepared to transition to independent practice at the end of the year, and it is important that you maximize your time as a fellow to develop into an independent surgeon — take note of things that your mentors do that work well for you, and things that you would do differently. Pay attention to the complications and suboptimal outcomes that you see during fellowship, and identify how your mentors deal with these. Finally, identify mentors who you can trust and continue to speak to over the course of your career — you will continue to need and rely on their advice and input in your practice whether you choose private practice or academics, particularly in early practice when you encounter difficult or complex cases.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Giving life advice to a physician yet alone a subspecialist seems imprudent and inconsequential, unless of course the audience possesses a smattering of self-awareness and humility. Describing oneself upon graduation aside, the advice would be open mindedness and observation. So many have trained before us and accomplished so many good things. Patients trust our judgments and experience; they are the recipients of our good fortune. And lastly, avoid the grifters in all walks of life.

Robert Bray Jr., MD. DISC Sports & Spine Center (Newport Beach, Calif.): Consider the area you wish to live for lifestyle and your family as a primary choice of where to start. Do not expect that the first spot you choose will necessarily be your career. I have told people that I am now on my fifth career, from the U.S. Air Force through academia to private practice and now outpatient. Make sure that you are building "you." It takes several years to develop your name, reputation and business skills. Avoid falling into what I consider pigeon holes (workers' comp and personal injury), unless you have decided carefully that is the path you wish to take.

Focus on quality and patient relationships, with good decision-making put above the rest. Carefully use new technology. There are many advances that are happening, but nothing replaces cost-efficient, quality outcomes and keeping patients happy for building your name and reputation.

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): My advice to those finishing training in residency and fellowship programs, would be to not only master and refine techniques in all aspects of patient care but to also grow in their understanding of the business of medicine. 

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I am now about 15 years out of residency. Many hard lessons have been learned, and had I had a mentor or someone senior to me, I would have had an easier time getting to where I am. But if I was able to give some advice to a younger me, or a colleague, I would advise three important things: First, be firm in your ethics and do not let any supervising partner, entity or bean counter talk you into being dishonest in your billing or coding. It is not worth your career. Second, do not be so full of hubris to ask for a colleague to have a second look at one of your hard cases. You will inevitably learn some things you never did or experienced in training. Lastly, know your worth. Do not ever let someone — especially from administration or an insurance company — devalue what you do. You heal patients and sacrificed so much to get where you are. Your ethics and hard work should never be a liability.  

Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): I think medicine and physicians are increasingly employed, but it’s important for physicians to maintain excellence and strive to better their brand and value.

Albert Wong, MD. DOCS Spine Orthopedics (Los Angeles): Residents and fellows should have an honest evaluation of their weaknesses and their skill set. They should get as much experience as possible to strengthen their weaknesses before the responsibility is truly on them. Find the attendings, surgeries or fellowships that will provide you more experience to strengthen your weaknesses so that you are prepared for the real world on your own. 

There are many solutions to solving a single problem and some are better than others. You should have multiple tools in your bag to avoid becoming a one-trick pony. Operating is easy and is not the issue for most people. Learning how to troubleshoot and solve complications when things do not go as expected is the key to being successful. With meticulous preoperative planning you can prevent many complications from even occurring. 

The younger generation needs to feel confident in their spinal anatomy for freehand instrumentation. There are many smaller hospitals that do not provide navigation, robotics or virtual reality surgical tools. Many of these hospitals will have fluoroscopy as your only image guidance. We have had cases where the O-arm navigation broke down in the middle of surgery and we had to revert to standard freehand technique with fluoroscopy. Please do not become dependent on technology In order to have a successful surgery. Sometimes the technology is inaccurate or unavailable and you will have to complete the surgery without it. This is analogous to everyone being dependent on GPS for driving navigation. If you end up in a rural area without GPS, you should still be able to navigate your way home based on the street signs and the map.

For your first year in practice, you should minimize performing high risk or very complex surgeries. You want to build a good reputation in your hospital and in your community. If you make too many mistakes early on in your career, you could develop a bad reputation among your peers and in the hospital that can significantly impair the growth of your practice.

Mentorship from your new senior partners is probably more important than your salary or location. Half of new graduates will pursue a second job elsewhere in the first five years. Having good mentors to enhance your professional development, improve your clinical and surgical skills, and guide your financial growth in a legal and honest way is imperative for every new graduate. 

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Keeping the patient at the center of everything we do comes naturally as physicians, but there are so many forces that push us towards increasing volumes, increasing productivity. At the end of the day, the most important thing is doing what is right for every patient. Whether joining a health system or private practice, look for that cultural fit that helps you succeed, stay true to your values, and supports you as you build your practice. The only constant is change. We are likely to face many changes in the coming years and decades to how we practice and even how we are compensated. Find the opportunities in those changes to continue growing as a surgeon. 

Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): Understand your indications. We are seeing more new surgeons coming out of fellowship with much less experience in clinic. The threshold for operating seems to be lessening. Set realistic expectations for your patients and try all conservative management strategies. Good outcomes will set the tone for your practice and you will discover that the best method of marketing is your patients telling friends and family of their successful outcome.

Chester Donnally, MD. Texas Spine Consultants (Addison): Pay attention to post-op protocols, discharge medications and how to treat "pain" that is six weeks or three months post op. My hero, Mike Wang, MD, famously said that "surgery becomes the easy part," and he could train a monkey to do it, but the hard part is diagnosis, which surgery is best and how to take care of the patient. This includes knowing when they can drive, golf, exercise and how to help with any post-op issues.

Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): Spine surgeons graduating from residencies and fellowships should take ownership of their career and its path. During the course of training, spine surgeons are often taught to follow the advice and patterns of the predecessors, faculty and mentors without question. However, upon graduating, one will find that there is an immense openness to the path that lies ahead with room for exploration. I would tell graduates, "Chart the course that you desire!" The future should be exciting with so much potential to mold it. It is the first opportunity to choose how one wants their work-schedule to appear, to have more influence over work location geographically, and to decide what style of practice on which one would like to focus.

Azam Basheer, MD. Henry Ford Health (Detroit): The first year of practice is always a challenge, no matter the setting. After intense, supervised surgical training for six to eight years, you are now expected to make decisions and surgical plans that were, for the most part, made for you. As a recent graduate myself, I found that transition to be the most difficult. One of the biggest challenges for new graduates is knowing when not to operate. Unnecessary surgery and procedures continue to be a pressing issue in spine care today. A recent article in Becker's estimated that more than 50 percent of spine surgeries performed in the U.S. are avoidable through conservative treatments. As residents and fellows, we graduate with a mindset geared to offering surgery and operating, but oftentimes the best thing you can do to help your patients is your comforting words and guidance. When in doubt, err on the side of conservative treatments. Don't underestimate the power of physical therapy and less invasive interventions.  Surgery is not always the answer to back pain.

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