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First Steps Out of Fellowship

by Elizabeth Hofheinz, M.Ed., M.P.H., June 14, 2019

Armed with the most up-to-date techniques and technologies, each year hundreds of orthopedic fellows emerge from the educational cocoon and head out to begin their full-fledged professional lives.

And if, as the venerable Lao Tzu said, a journey of a thousand miles begins with a single step, then that first step—and the ones that follow—will ideally point you in the right direction.

While there is no manual for how to proceed out of fellowship, we offer a few tips from two orthopedic surgeons who completed their programs in 2018.

Wesley H. Bronson, M.D., an orthopedic spine surgeon for the Mount Sinai Health System and an assistant professor in the Department of Orthopedic Surgery, completed a year of subspecialty training in spinal surgery at the Rothman Orthopaedic Institute at Thomas Jefferson University Hospital in Philadelphia.

Wesley H. Bronson M.D.

Asked about transitioning to this new period in his career, Dr. Bronson told OSN, “For me, the fundamental issue was how I would build a practice in a competitive environment—New York City. While working at a large academic medical center confers certain advantages and conveniences—such as the referrals that come in—I must always consider that it is a large market and I am not the only good surgeon in the area.”

“My basic rule is that I am always available. When I speak to PCPs or physiatrists I explain the kind of care I provide, how I can collaborate with them, and that they can reach me at any time. Just as I am not an expert on heart conditions, I wouldn’t expect a cardiologist to know much about orthopedics…so when they want to know if they are making an appropriate referral then I will be at the other end of my cell phone to help them. I genuinely enjoy the process of communicating with other providers about taking care of our patients and feel that collaboration in terms of the type of care needed and how to expedite that care is critical.”

As for adjusting to your new work environment, Dr. Bronson notes, “No matter who you are when you come into an environment where no one knows you it’s going to require some work on your part. You have to get to know the PCPs, pain management specialists, anesthesiologists, etc., and educate them about the kind of practice you have and what kinds of patients you can help them with. It’s early in my practice and I will see anyone my colleagues ask me to—whether or not it is a surgical patient.”

“The fact that you collaborate with PCPs, physiatrists, etc. also makes the patients feel more comfortable. It sends a message that you are treating the whole person and that you are willing to go the extra mile to help them. Maintain that dialogue…close the loop…maybe they thought the patient had one diagnosis, but in reality, they had another.”

Asked what a newly-minted fellow should never do, Dr. Bronson told OSN, “Don’t cut yourself off from any type of case…even if you are not on call or it is not a convenient time for you or a colleague sends you someone who is wrong for your office…see them! Be happy that people are entrusting you with patients and do your best to keep a positive attitude.”

When it comes to dealing with the hospital, says Dr. Bronson, be flexible. “In your residency program they did things one way, and in your fellowship, they had another specific way to do things. Now you are in a hospital setting where things are done yet another way. Each way is safe, but there are intricacies of the way a hospital is run that are different from what you are accustomed to. While it is comfortable to be stuck in our usual ways it is ultimately better to be flexible.”

Miles T. Birmingham, D.O., joined OrthoVirginia after completing a fellowship at The Cleveland Clinic. Echoing the sentiment conveyed by Dr. Bronson, Dr. Birmingham emphasized to OSN, “I said ‘yes’ to any type of case. I made sure to approach different family and concierge medicine practice and introduce myself. I knew that I would be my biggest advocate and that no one could represent me better than I could myself. The fact is that I was the new kid on the block, and I had to find a way to bring my own personality into a new and very conservative medical environment.”

Miles T. Birmingham D.O.

When asked what he wished he had known before embarking on a full-fledged practice, Dr. Birmingham notes, “It would have been helpful to have a better sense of how difficult it is to start from nothing, especially when you do not have much of a support system. Dictations, billing, call coverage…I could have benefitted from more information up front on those topics. Billing, in particular, is a monumental subject. I would have liked to have had a deeper understanding of its complexity, how to make good decisions in that arena, and how billing affects reimbursement. For example, you can do the same amount of work—or even more—and because you do not bill correctly then you earn much less.”

On the hospital front, Dr. Birmingham had a pleasant surprise. “I have been in a hospital environment since medical school so that itself wasn’t new. What I did not realize is how much respect you gain when you transition from being a resident/fellow to an attending. It was a monumental jump.”

And what does he recommend that a “new” orthopedic surgeon never do? Take on cases for which they are not trained. “If someone is handed a call case or if they don’t want to ask a partner for help then they may try to take on something without help. That could jeopardize patient care and outcomes. It would be more prudent to send a patient to an academic center than try to tackle a case for which you are not prepared.”

And if Dr. Birmingham were allotted a few minutes “on the podium” to transmit messages to those about to complete fellowship? “I would show fellows the cases I had in my first two years and ask them how they would proceed, including how they would plan to bill for them. I would talk to them about my successes and failures, all the while making it interactive so that the fellows had ample opportunity to pose questions. I’m not perfect but I’ve done a lot in almost two years. While there have been a few failures there have been many more successes. So, for my colleagues just exiting fellowship I would lay out my journey and what it took for me to achieve so much in such a short period of time.”

Any fellowship programs listening? Ready to bring in some former fellows to help guide current trainees to success?

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Elizabeth Hofheinz

Two time winner of the MORE award Ms. Hofheinz was the first writer employed by Orthopedics This Week. The MORE award is granted annually by the American Academy of Orthopaedic Surgeons to recognize excellence in journalism. Ms. Hofheinz resides in New Orleans, Louisiana with her entrepreneur husband and delightful daughter.

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