Charles B. Mikell, Joseph Adachi, Jennifer Cheng, Joseph S. Neimat

Abstract

This chapter is intended for newly trained functional neurosurgeons and describes key elements and considerations within the first years after training to establish a successful functional neurosurgery practice. This chapter lays out what a newly minted neurosurgeon can expect from the field of functional neurosurgery and helps to define the scope of personal and professional goals which will be achievable within the various practice settings. The pros and cons of private practice, hospital, and academic practices will be discussed. Further, the chapter dispenses advice relevant to the finer details of negotiating a contract, building a research lab, clinical team, referral network, and professional reputation. Although the chapter is focused on the early stage of a neurosurgical career, elements will certainly be applicable to those further along in their practice or those wishing to begin a new facet of their career.

Keywords: practice-building, functional neurosurgery, DBS, practice-management, professional development, 2018, referral networks, neurosurgery residency, neurosurgery

Among the first things a newly hired functional neurosurgeon has to do is build a practice. This is invariably a more complex process than in some more traditional practices, because it necessarily involves the organizing and motivating a large and multidisciplinary group. Notwithstanding these increased challenges, we believe that the creation of such an effort can be one of the most rewarding aspects of a functional neurosurgery career.

Despite the ultimate importance of this activity, new graduates have often received little training or guidance in how practices are built. Although each environment has unique challenges and opportunities, we feel there are some common themes that merit discussion and incorporation early in the process of building individual practice. This chapter is an attempt to summarize those common strategies and think constructively about the goals that such practice elements serve.

We suggest three main elements to successful practice building. First, it is important to know what you want. Ask yourself what your “dream job” actually looks like. The second element of a successful practice is the right environment: the right department, right partners, right neurologists, and right chairperson. The final element is the right approach to your patients, your collaborators, your institution, and your practice environment.

γνῶθι σεαυτόν – “Know thyself”

-A Delphic maxim, inscribed on the wall of the Temple of Apollo.

Neurosurgeons, no exception to the population at large, are quite capable of resisting self-examination. The beginning of one’s career is an especially important time to pause and reflect on the specific aspects of a surgical career that will be most important to you. A failure to be introspective and deliberate about how a career is built invites the inevitable chaos of a surgical practice to make its own determinations.

Most people who are interested in functional neurosurgery are fascinated by the science of the nervous system and by the opportunity to manipulate and investigate its functions. Nonetheless, the cases themselves can be tiresome, and are not as well-compensated as other procedures in neurosurgery. It is, therefore, important to know what cases you want to do, and how often. If you do not have clear goals, you will inevitably have difficulty arranging your priorities and may eventually find your schedule strangled by obligations not of your choosing.

The next question to ask yourself is how much money will be enough for you. In functional neurosurgery, “[they’re] electrodes, not screws. Nobody’s getting rich,” as one colleague recently reflected. Therefore, almost all functional neurosurgeons incorporate other elements of neurosurgical practice into their career. Establishment of these ancillary elements are outside the scope of this book, but should not be overlooked in helping an individual achieve both financial and intellectual balance. Ultimately, functional neurosurgery is not so poorly compensated as it is widely believed to be—although spine surgery certainly pays more. A recent survey of functional neurosurgeons found that their salaries tend to be commensurate with the 50th percentile of academic neurosurgeons. The Goldilocks zone that balances the: case mix, research time, and compensation that is “just right” for you, is the key to long-term happiness. And it will be important that you have a frank and honest discussion with your chair about these goals before you sign your contract. When you believe you have answered these questions, you are ready to start making more specific decisions to build your future practice.

For many of us in academic medicine, success is predicated not only on excellence in the clinic and operating room (OR), but in the conquest of the domains of research and teaching as well. This classic three-legged stool—a rare feat, has long served as the precarious metaphor for achievement in academic medicine. Inevitably, as career progresses, administrative roles become an important fourth leg of one’s endeavors. In the private practice setting, formal roles in education and research are less common but can nevertheless be pursued and successfully integrated into one’s practice.

If such endeavors are important to your job satisfaction, recognize that they will take considerable time and commitment. Teaching can be a satisfying activity; watching your trainee perform a simple or complex procedure for the first time, independently, can give a tremendous sense of accomplishment. Most new graduates have had some experience teaching junior residents and will have a sense of whether they are drawn to education. In academic medicine, most departments will have some expectation that you lecture a few times each year, but if you want to do more, this will almost certainly be accommodated. Early in your career, it can be challenging to share responsibility with residents, as you yourself are consolidating operative confidence. Striking this balance is ultimately rewarding and becomes easier with a few years of experience. Most surgeons become better teachers over time, if they are willing to listen and attend to the feedback they receive from their trainees early on. There are some drawbacks of a major teaching role. These include the time required to prepare educational materials, as well as the constant and taxing requirements to provide documentation of how your trainees are progressing. In 2013, as a response to criticism from previous years that educational requirements in neurosurgery were “fuzzy,” the American College of Graduate Medical Education (ACGME) in consultation with the Society of Neurological Surgeons (SNS) developed a curriculum of milestones required for each resident to achieve. These milestones have indeed improved the standardization of training but are quite paperwork-intensive. In short, there is no doubt that a committed role in education will require the dedication of significant time. Moreover, for those who wish to be a teacher or mentor, few time investments are personally fulfilling.

Likewise, a serious research career can be both satisfying and frustrating simultaneously. You should decide early on if you are going to initiate your own research or collaborate with other scientists. If you want to be a principal investigator yourself, you will need to have an explicit conversation with your chair about the time and resources that will be available. Competition for your time will be great and you will need to protect your dedicated research time vigilantly. The most critical support will come in the form of personnel. One full-time employee is probably a bare minimum requirement. You will also need lab space and money for resources (animals, computers, or whatever else). While starting out, most chairs are able to furnish you with some resources… with the expectation that you soon establish your own grant funding. Resources in academic centers are increasingly scarce; there will be a defined period for which a “startup” package will be available and after that point you will need to secure your own money to keep things going. In addition to working toward publications, your early time should be spent obtaining pilot data for grants. Until you have your own grants, you should expect to spend an equal amount of time writing pilot grants, just so you can stay in the game. You should also expect significant paperwork associated with Institutional Review Board submissions, animal care, and other related activities. As funding is established, either from the National Institutes of Health (NIH) or private foundations, pressure on you will start to ease; however, the challenge of funding will last as long as the lifetime of the lab.

Despite the time commitment and challenges associated with doing research, the opportunity a functional neurosurgeon has to learn about the nervous system is unique. Your position will grant you daily, direct access to human neural activity which, until the recent birth of our discipline, no human in history has ever had. You will also have the unique ability to integrate the latest advances in electronics and neuroscience to manipulate brain pathology with electrical stimulation. It is an auspicious time for clinical researchers in this small field that shows great promise in revolutionizing the landscape of neurological and psychiatric illness.

Once you have decided how much teaching and research you want to do, you should briefly think about how your week will be arranged. Most neurosurgeons start out with 1 to 2 clinic days, 1 to 2 OR days, leaving an unscheduled day or two for academic activities. Maybe you want to have two research days, but are willing to make less money. Or maybe you want to be the guy who does 300 cases a year. You should think through all of these possibilities carefully, and discuss this with your chair. In private practice, less flexibility is available because your job is chiefly to do cases. But even in the private setting, your schedule should reflect your priorities.

The majority of neurosurgeons in the United States are in private practice. However, only larger, subspecialized private groups of 10 or more surgeons are able to support a dedicated functional neurosurgeon. It is fairly unusual for small private groups to employ a full-time functional neurosurgeon, but it is not uncommon for one surgeon in a smaller practice to have an interest and offer deep brain stimulation (DBS) and epilepsy surgeries as a subset of his otherwise general practice.

In either environment, the incorporation of functional neurosurgery will allow a practice to market themselves to payors and hospitals as “comprehensive” providers of neurosurgical care, and it may translate to better leverage when negotiating reimbursement. If the group is large enough, you will have peers with whom to discuss complex cases. These large groups may also employ dedicated administrative staff to assist with practice building. As we will see, many of these advantages are shared with hospital-employed positions.

Over the past decade, large academic groups that have staffed large hospitals have faced pressure from the hospital to join their employed staff. Likewise, hospitals have also sought to hire their own neurosurgical staff to secure financial advantages over private groups. There is probably no reversing this trend; each year a larger and larger proportion of neurosurgeons in the United States are working for hospitals. The hospital-employed model does have some benefits but has a few drawbacks also. As with a large private group, it handles a lot of the administrative work for you; but this, of course, is a double-edged sword. A professional administrator may take on these responsibilities for you, but this change may be felt acutely as a loss of autonomy. You may have little control over who is helping you in the OR or whether you have physician extenders for the floor. Finally, hospitals are generally able to offer higher initial salaries than their academic counterparts due to their size and resources; however, they will typically make significant demands on clinical productivity, and if high targets are not met, they can play “hardball” in contract renegotiations. Ultimately the success of a position, be it private, hospital-employed, or academic, will depend on shared goals between you and your employer. If aspects such as teaching or research are important to you, be certain that the hospital administration understands the value you bring to their program and is committed to supporting your extra-clinical goals. It is critical that your employer’s expectations are compatible with your identified goals.

Academic departments typically employ one or more functional neurosurgeons, as functional cases are now a part of the ACGME requirement for residency training programs. Academic departments are the traditional centers for teaching and research, and you may find there is increased prestige with being linked to an academic center. The cases that come to academic institutions are typically more complex and may include those that are passed over by community physicians. Other advantages over community practice include better ancillary services at large academic facilities, and more direct access to collaborators in neurology and other specialties. Partnership with neurology collaborators, in particular, is critical for building effective teams in a functional neurosurgery practice.

Although academic salaries are somewhat less than the private salaries, these positions typically emphasize research and education as an important part of your activities. Although most academic departments still incentivize clinical productivity, the best positions strike a balance between clinical duties and academic opportunities to achieve a salary that is fair. Again, it is critical to establish what benchmarks your chair will use to evaluate your productivity when the time for contract negotiations and/or promotion comes.

Once you have started your job, the work of building a practice really begins. If there is an existing functional neurosurgeon, and your job is to be a release valve for the backlog of his or her patients, a lot of the team building has already been done for you. In this case, it will be critical to have a good communication with your partner or partners. Make sure you understand how cases and responsibilities will be shared and all the partners are comfortable with this arrangement.

Movement disorder neurologists have traditionally been the most eager neurologists to embrace surgical treatment for their patients. DBS can have such a dramatic effect for Parkinson’s disease and tremor patients that they are usually enthusiastic about a new surgical program. However, program building will require a significant time commitment with your neurology partners and it is important to recognize this. If your neurology colleagues have an academic interest in DBS surgery, this relationship can be tremendously synergistic. As a bonus, their clinical time expenditure is usually offset, to some degree by the ability to bill for high-complexity visits when they program, in addition to billing the programming codes. Ultimately, collaboration with movement disorders neurologists is natural and the rewards are mutual and substantial.

Pain physicians have related but distinct considerations to those of movement disorder neurologists, but they should be equally enthusiastic about your presence. Pain physicians typically perform initial percutaneous spinal cord stimulation (SCS) trials, and subsequently refer patients for permanent implantation. If they have been sending patients outside for treatment, they are typically happy to have someone at their home institution. An important distinction from movement disorder neurologists is that percutaneous spinal cord stimulators simply lack the efficacy of DBS and the patient population has lower satisfaction levels in general. SCSs also have significant rates of migration requiring revision, so it is important that the pain physicians understand that not every patient will be a “home run.” Good pain partners understand this and make allowances for suboptimal outcomes in preoperative counseling. In general, pain physicians are acutely aware of the lack of safe therapeutic options for intractable pain, and are pleased to have your services available within the team.

Epilepsy has traditionally been the most challenging area to make inroads. Resective epilepsy surgery lacks the immediate gratification of DBS implantation and is perceived to carry significantly more risk. For this reason, some epileptologists have been hesitant to recommend surgery for their patients. Recently however, attractive surgical options have become available that are substantially less invasive at the time when it is increasingly accepted that serial medication trials are unlikely to provide meaningful improvement. For this reason, we expect to see substantial growth in epilepsy surgical practice in future years. In a growing program, referrals will typically increase as your neurologists gain familiarity with the new options available for treatment (for MRI-negative epilepsy in particular), such as laser ablation and responsive neurostimulation (RNS). You should meet with the division chief of epilepsy surgery early on, and come prepared with evidence from recent trials demonstrating the benefit of surgery over continued medical management. You should try to agree on which patients should receive surgery, and to establish a recurring conference date to discuss new cases. As you successfully treat more and more patients with surgical therapy, your referrals will likely grow.

To successfully screen surgical patients, you will need additional team members other than your neurology colleagues. For DBS programs, the multidisciplinary team typically includes one or more neuropsychologists. These staff are often divided conceptually into preoperative and postoperative roles. Preoperatively, these individuals interpret functional tests and provide guidance to patients regarding specific risks of surgical intervention such as functional deficits and disability. Preoperative evaluation is often part of the workup for seizure focus localization and may reveal additional cognitive deficits and latent mood disorders prior to surgery. These insights can be critical for judicious patient selection and successful management. Postoperatively, neurophysiologists monitor clinical outcomes, arrange follow-ups, and assist with the smooth transition of care to specialists in rehabilitation.

A surgical patient coordinator, dedicated epilepsy monitoring unit, and team of experienced EEG technicians are also crucial. Because of the complexities of managing DBS patients, many groups have incorporated advanced practice nurses trained specifically to assess and program DBS patients, as well as patient navigators who coordinate patient access to the many specialists within the DBS team. It is commonplace for programs to utilize a psychiatrist, either as a standing member of the committee or as a frequent consult who is called in on an ad hoc basis. Their insights are invaluable when, as is often the case, psychiatric comorbidities are present. In addition, neuroimaging capabilities such as those provided by experienced neuroradiologists are key in the identification of subtle abnormalities, such as mesial temporal sclerosis, cortical dysplasias, migration abnormalities, and encephaloceles. Finally, a dedicated neurophysiologist or scientific partner may assist in the OR if you prefer to not always perform the neurophysiology yourself.

DBS surgery, in addition to vagus nerve stimulation, RNS and SCS, features an implanted device, hence the companies producing these devices have an important synergistic interest in promoting your surgeries. Whether you choose to engage them or not, there are representatives from almost every company in your market working to promote the surgeries that you perform. Among physicians, there has been a general mistrust directed towards these corporate interests and sales people. Fundamentally, however, it is our belief that their conflict of interest is no greater than our own conflict as physicians who are ultimately paid to perform surgery. We, therefore, feel that working with these agents is mutually productive, provided we encourage them to apply the same integrity that we hold ourselves to in selecting appropriate patients and withholding surgery for those we feel will not be helped.

With this in mind, corporate partners can be invaluable allies in patient education and practice growth. They can assist you with introductions to potential referring physicians (they typically have access to data on high-volume referrers); access to patient groups; and an ability to get your name out to these groups. Since there is now competition among several device manufacturers (as there has been in the SCS space for some time), it is important to be forthright in your interactions with each representative. In our practices, we have worked to select devices based on their clinical merits and allow our patients to independently decide which implant they will have, after the advantages of each are dispassionately presented.

Everyone has heard the three A’s: affability, availability, and ability (in that order). However, you should think carefully about what these words actually mean for you. Everybody wants to refer to a nice person. Affability means being nice to other providers, and maintaining a polite and professional attitude at all times. When you start out, you should make every effort to reach out to referring providers when they send you an operative case. If you provide a positive experience for operative referrals, more referrals will come to you. If you are easygoing and polite to everyone, they will remember that and seek out your help next time. Whereas, if you get a reputation as a person who is difficult to talk to on the phone, people won’t want to refer to you. Of course, this is easier said than done, especially when the ER attending calls you at 3 AM to admit a nonoperative patient to your service. But you should try anyway. This also speaks to availability.

Availability is a more slippery concept. You want to be available, but not so much that you compromise your personal livelihood. Early on, you should talk to whoever manages your outpatient schedule with the goal of prioritizing operative referrals. In our group, brain tumors get seen as soon as possible, for instance. You should make similar allowances for epilepsy and DBS patients. You should also make an effort to prioritize personal referrals over referrals to the “first available” neurosurgeon. Again, when someone sends you an operative case, call him or her. If someone calls you to see a patient, see the patient as soon as possible. You can even offer to visit the patient at the referring physician’s office if circumstances allow. Some practices have shared clinics where movement disorder patients see their neurologist and neurosurgeon in the same day, greatly facilitating patient flow. Patients who experience a smoothly run preoperative and postoperative course are typically happier and may convey this to their primary physician or other potential patients.