Billing, business and more: What 7 spine surgeons wish they learned in medical school


After undergraduate education, spine surgeons have to complete medical school and a residency before working as surgeons. It's not uncommon for spine surgeons to have additional training through fellowships.

Still, many spine surgeons say there are skills they wish they learned sooner in their education. 

Here's what seven spine surgeons wish they knew going into their careers:

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 developments do you think will come next for sacroiliac joint fusion in 2023?

Please send responses to Carly Behm at by 5 p.m. CST Wednesday, Feb. 15.

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

Question: What's one clinical or nonclinical skill you wish you had learned when training to become a spine surgeon?

Jeremy Smith, MD. Hoag Orthopedic Institute (Newport Beach, Calif.): Surviving the current healthcare climate in a private practice setting is difficult. Understanding evolving policies and adapting our practice to continue to provide optimal healthcare and be successful as a business is mandatory. During my training, I wish I would've understood this need and committed my education to developing a foundation in the business of medicine. I found out in my first few years how necessary this is. I believe training programs for residents and fellows should commit part of their academic agenda to these principles. We need more advocates with business and political acumen to survive in the future. 

Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): I would have liked to have a better introduction to billing and business management during training, as these factors are important but generally learned on the job.

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (Livonia, Mich.): Practice management is significantly overlooked and under-taught in the training process to become a spine surgeon. The one nonclinical skill that I wish I had been given more exposure to is physician billing knowledge. Several studies have indicated that a large number of physicians acknowledge their inexperience with billing, and this decreases billing accuracy. An even larger number of physicians stated that they have a strong desire for more billing education during training. Even experienced physicians can miss a substantial amount of potential revenue because of billing errors and omissions. Appropriate coding and formal educational courses should be taught. I believe all physicians should attend a dedicated medical-legal and billing/coding course.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: One clinical skill I have learned is how to assess the sacroiliac joint. This is an incredibly useful skill that can supplement your physical exam when trying to assess the pain generator in certain spine patients. While not a magic bullet, it really does allow the surgeon to think outside where you are normally comfortable and look at other sources for the patient's pain. Many sacroiliac dysfunction patients can present looking like a spine problem. Over the years, I've developed a protocol when this sort of patient presents to the clinic. I have yet to do many SI joint fusions but am looking to do more of these in the coming years on very select patients.

Edward Perry, MD. Swift Institute (Reno, Nev.): Clinically, I would like to have learned more about the often beneficial role of acupuncture in axial and radicular spine pain treatments, and how understanding the mind-body connection of pain perception could contribute to successful outcomes for my operative and nonoperative patients. This is of course not expected of allopathic medical training, but nevertheless, has enough application in my current practice that would have been helpful in the past 10 years of experience after fellowship.  

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): I was lucky to receive great training during my residency and fellowship that prepared me well for a career as a spine surgeon. I graduated in 2010 when the field of minimally invasive spine surgery was in very early stages, so I did not get much exposure to it. As I got out into practice, I started learning more about minimally invasive spine surgery and took time out of my practice to learn minimally invasive techniques. I was able to transition to MIS spine surgery practice in the first few years of my career.  

In 2020, I opened my solo practice with my wife as my practice manager. There was a great deal that we had to learn (and very quickly) about owning and operating a business in general and medical practice in particular, including contracts, licensing, negotiating with payers, office maintenance, compliance with various state and federal regulations, billing and collecting, etc.  It would certainly be helpful to have had more of such training during my residency and fellowship.  

Nowadays I have a thriving MIS spine surgery practice. I try to pass on the knowledge I have gained over the years to other surgeons, residents, fellows and medical students by teaching courses and serving as faculty at a local medical school.  

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): Clinical skills can be learned because new techniques and new data evolve all the time. One skill that I wish I should have learned more about is how to pick and choose reliable data/evidence to help improve patient outcomes. We are in the era of data overload. The other skill I wish I could have learned more about is management skills, along with some other skills on the business side of medicine, to be able to provide quality care at a lower cost.

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