[The following is part 2 of an edited transcript of a video recorded in August. Part 1 was published in our October issue.]
| P A N E L I S T S | |
|---|---|
 | Bariatric and Minimally Invasive Surgeon Dr. Mona Misra Advanced Surgical Specialists Inc. Cedars-Sinai Medical Center Beverly Hills, Calif. |
 | Chair, Department of Surgery University of California Irvine Medical Center Immediate Past President, American Society of Metabolic and Bariatric Surgery Orange, Calif. |
 | Medical Director of Bariatric Surgery and Obesity Medicine CHI Memorial Hospital Past-President of the American Society for Metabolic and Bariatric Surgery Chattanooga, Tenn. |
 | Column Editor and ModeratorProfessor of Clinical Surgery, Chicago Medical School Rosalind Franklin University of Medicine and Science President, Chicago Institute of Advanced Surgery |
Dr. Lutfi: Welcome back! Dr. Ponce, we were talking about money when we left off in Part 1. I’m going to make this question blunt: If I’m just hungry for money—I’ve been poor all my life, now I’m a surgeon—looking at 10 years down the road, what would be the best financial decision for surgeons if finances are very important to them?
Dr. Ponce: This is a very good question. As has already been said, the worst thing that a new graduate, the new surgeon, can look at when considering a new job is the salary. If you look at that salary and you think that that’s what it is going to be 10 years from now, that’s the worst thing you can do. You need to look at the practice, the support, the surgeons you’re going to be working with, the hospital if you are a hospital employee; and also what Mona said [in Part 1] is very true—do not start in solo practice. In today’s environment, you’re not going to survive. If you go into private practice, go to a group in which you will have support, and you can grow and go from there. Ten years from now, things are going to be very different than today.
Dr. Lutfi: About a year ago, we did a survey for bariatric fellows at one of the bariatric meetings, and we asked two things. We asked them if they felt that fellows would soon start paying for their own fellowships instead of taking a salary because we’re running out of money for education. Many felt that future fellows would have to pay for their fellowships. This surprised us. We also asked about socialized medicine or a single-payor system, and we were intrigued to learn that a lot of the fellows think we are moving toward a single-payor system. So, knowing this, what do you think of any changes that will affect the three types of practice over the next 10 years, not just for younger surgeons, but for general surgeons in the community?
Dr. Nguyen: At the current state, the gap between academic, private and employed surgeons is getting narrower. There used to be a wide disparity in income, meaning private practice was much higher than that of academia, but I would say times have changed, and I’m glad to hear your responses—it’s not all about the money. I think a lot of people are going into academia because of the opportunity for educating students and residents and being involved in an academic system where everybody is thinking on the same theme—the next research project, inquisitive minds finding answers to questions and the ability to educate the next generation of surgeons.
With that being said, academic compensation is benchmarked by the AAMC [Association of American Medical Colleges] standard, so salary compensation for academic university employees across the nation is published; it’s all available. The same thing [goes] for the private sector, the MGMA [Medical Group Management Association] compensation data are available. I would say the AAMC compensation is not as high as that of MGMA, but it’s getting closer. It’s hard to predict where we will be 10 years from now. I really don’t think that there will be a day when the fellow is going to have to pay to do a fellowship; that would not be a fair system. They do clinical work, they should be compensated for it even if it is during their training. What do we expect down the line? I think running an academic surgical practice will continue to have its own challenges. However, it is important for the surgeons to be integrated with the hospital or the health system to develop a model that is favorable for both the surgeons and the health system.
Dr. Lutfi: Dr. Misra, being in private practice, I worry about this every day. I have now two major value-based contracts where I pay for my own bariatric complications. I have a lucrative contract, but in that contract, if I take a patient back for a bleed, I pay for it. If I have a patient with a leak and that patient stays for a month and get stents and a reoperation, I pay for it. Cash pay aside, do you think someone like you can still be in practice in 10 years knowing that insurance companies are changing, with big contracts, big mergers? What do you think?
Dr. Misra: So that concerns me, and I think everyone in private practice worries that in 10 years we’re going to struggle to make any benefit of having a practice like this. I’m glad we’re talking about it because, unfortunately, I think we have to fight for it. I think in any field, whether you’re employed or not, the surgeon’s pay is constantly being decreased. We’re seeing that in the news all the time, no matter whether you’re doing bariatrics, general surgery—[it] doesn’t matter—the pay per procedure for surgeons and physicians is decreasing, and I think that it’s sad because we work really hard to be as good as we are and then to provide the best care for our patients.
I think the only way we can protect ourselves is keeping track of our outcomes. I’m sure that’s how you managed to get those great contracts, Dr. Lutfi—you showed your outcomes and that you rarely have any issues. But it’s still stressful because sometimes you can do everything perfectly and something can go wrong—it’s the nature of the beast. It’s frustrating that, to be able to be paid what we’re worth, we are going to need to struggle. Again, we’re all trying to do our best and provide the best care possible for our patients, and it shouldn’t be financially motivated, and it isn’t for most of us. We look at the practice itself and see what we enjoy about the practice, and for me it fits my lifestyle, but I think we have to fight for it. I think we are potentially moving toward more concierge medicine and things like that, where the patient is taking on the cost, and I still think that’s not fair. I struggle with what the future holds, and I think we as physicians have to fight to hold our space.
Dr. Lutfi: Very nicely said. Dr. Ponce, I think this may be depressing for people who are listening. Is there anything—with you being involved with so many different entities—that you see as positive in the next 10 years for surgeons who are early in their careers, or mid-career?
Dr. Ponce: I think things are going to be different—not necessarily bad, but different. This is what I want to emphasize: Who is negotiating reimbursement for what we do? For individual physicians, the power for negotiation is low. Hospitals, they have more power to negotiate. Academic institutions, they still have power to negotiate because they may offer needed services for the community; for example, here, the level 1 trauma center still receives some money from the state. The ones who have the lowest level of negotiating power are the individual surgeons like Mona. Rami, because you have a big private practice group, you still have some level of negotiating power, but it’s still not as big as a hospital. So, 10 years from now, who’s going to get more money? Hospitals. Who’s going to get less money? Surgeons.
Ten years from now, what I see—and what we’ve seen over the past 10 years is the same thing—is less reimbursement per surgeon and more money for the hospitals. And so, hospitals are going to absorb more surgeons and they’re probably going to control the budget to take care of these patients. The sad thing is that now we have to depend on that budget, controlled by somebody else, to take care of patients. On the good side, there’s probably going to be a system in which surgeons are going to do what they like to do—take care of patients, and we probably are going to be less worried about the income. The income may be less than the income of some private practice surgeons, but it’s still going to be appropriate. To be a physician is not going to be bad. That’s my positive message—that it is still going to be good to be a physician; it’s still going to be exciting to take care of patients; and probably there won’t be as much worry about that individual payment because somebody else is going to control that from the hospital standpoint.
Dr. Lutfi: Any thoughts on long-term financial planning? The public university probably has the most robust retirement package of all the practice types—our private group provides a very good package with 401(k) and profit sharing, and so forth. Any words of wisdom to those who are about 10 to 15 years in practice, maybe 15 to 20 years, as they plan for the last third of their careers and think about retirement?
Dr. Ponce: Go with a good financial planner, regardless of the career you choose. You have to start planning that from day 1. You cannot just say, ‘Well, later on I can plan my life.’ You need to start from the beginning. Even if you go to a private practice, or if you go to hospital employment, plan the way that you’re going to be saving money. I think academics—and maybe Dr. Nguyen will correct me if I’m wrong—they probably have the best package to take care of you if you stay in academics over time, for your retirement I mean, because you can still get some support even after you retire.
Dr. Nguyen: Yes, most universities have a pension plan, so if you are within a university health system that has a good pension/retirement plan, that could be very helpful. Our VA faculty not only receives retirement compensation from the university but they also receive retirement compensation from the VA. Additionally, I would also say that it is important for everyone to invest your money, and, as noted by Dr. Ponce, to seek expert help on this. Surgeons are great at medicine but not all of us are good with finance, so it is important to get expert help on this topic.
Dr. Lutfi: Great. Mona, any different thoughts?
Dr. Misra: No, I agree. I think that when you’re looking at 10 to 15 years down the road, both Dr. Ponce and Dr. Nguyen are making very valid points. I think for myself, if we start struggling in private, then I would like to move in that direction toward an employee-based practice.
Dr. Lutfi: UC Irvine or Chattanooga?
Dr. Misra: Dr. Nguyen, I’ll send you my resumÉ!
Dr. Lutfi: I wish I had my fellows behind the screen listening to all of this.
Dr. Ponce: I think Dr. Nguyen hit on something very critical and I see it all the time. For example, orthopedic surgeons in a hospital— that are all private practice and they built their own surgery center, so they do all the easy cases in their center and get paid well, and they send the worst patients to the hospital. When you have that model of not working together—they’re looking for their own benefit, like most do in private practice—and the hospital is getting affected by that model, but at the end of the day if we keep working against each other, the money is not going to be distributed in the right way. The model that Ninh suggested, in which the physician buys into the [integrated] model—and that’s why I think hospital employment is probably going to prevail in the future—is that everybody’s working together because we want the hospital system to be sustainable. The model of integration is going to allow things to continue to grow and it’s probably going to prevail in that way.
Dr. Lutfi: As we wrap up, I’m going to ask you all to leave with a word of wisdom and also any regrets you may have. I’ll start: I started my career as part of a very tiny group, so I kind of learned all the good and the bad—there was a lot of bad along with a lot of good people in the group. The group kind of fell apart and then I started out on my own. I applied to be employed and to academic positions. The only regret is that I saw it coming and I did not jump out as soon as I should have, and that destruction of the group could have really destroyed me. So, whether you choose academic, private or employed, my advice is look at the exit strategy, look at restrictions of trade, look at a lot of these things—a forgivable loan that suddenly is not forgiven—things like this. Ask yourself: If things don’t go well, what will happen? What is my exit strategy? Only by a lot of fortune and hard work was I able to stand again.
Jaime, any regrets? I know you have an incredible career—you just won the [2023 National Outstanding Lifetime Achievement Award in Bariatric Surgery by the TREO Foundation], which is proof of what you’ve accomplished—but any regret about anything that did not go well?
Dr. Ponce: “Regret” is a big word because I’ll bet you that all of us didn’t choose exactly where we are in the way that we wanted. The most important thing to remember is that you are not going to be able to choose that perfect practice. I will tell the new surgeons, “Even if you look at all the practices, none of them is going to be that perfect practice.” You should choose the one that you see as the best possibility to make your practice. Also, take advantage of all the different opportunities you have during your career, even if it’s not the perfect practice at the time. Take advantage of the resources that you have there in growing the way that you want it. I’m sure that Mona started and created the practice that she wanted. So, I don’t have any regrets because private practice gave me a lot of lessons, a lot of opportunities, a lot of challenges, but I used all of that to learn. And as a result of establishing a good, strong practice, I was able to get an offer to become an employee, so I don’t have any regrets right now.
Dr. Lutfi: Amazing. Ninh?
Dr. Nguyen: I wouldn’t say there are regrets, but perhaps missed opportunities. A couple of examples: Along the way, I was asked to evaluate positions at Duke University and at Mount Sinai Medical Center, in New York [City], but I never actually fully evaluated those opportunities. So, I would say, if you have those type of opportunities, you just have to have an open mind and evaluate them. Maybe my career would be completely different if I took one of those opportunities but it’s hard to know. I’m very happy with what I’m doing right now so I don’t think so. But I think for other people, when these types of opportunities that could change your career trajectory come your way, it’s critically important to look at them seriously.
Dr. Lutfi: Ninh, you’re absolutely right, as always. Mona, anything you’d like to add?
Dr. Misra: I agree with a lot of what every single one of you said. It’s not necessarily regret, but lessons learned. I would say anyone who’s joining a new job, get that contract read by a lawyer. I just think I was very naive the first time I came to the United States, and my thinking was, “I’m going to work, and we’re all going to work together and everything’s going to be wonderful,” and it’s not how life works. You need to protect yourself. It’s the same thing— your exit strategy is very important, and if it turns bad, you know, you go through the fire and you come out stronger, and you have to turn it into something positive. Every day, I am grateful for the job I have, the life I have, the people I work with. And I’m also very grateful for all the opportunities that have come my way, because I am standing on the shoulders of giants. I have had opportunities from you all who have helped me grow and learn and you’re wonderful mentors. I’m grateful for it, and I think we always should be grateful for opportunities that are brought our way and to make the most of them. Work hard and do a great job, and you’ll be happy with whatever the outcome is going to be.