Selecting the Best MCS Program for You Originally Broadcast: Thursday, January 28, 2021 5:00 PM Central Standard Time
MCS Fellows Program
Watch an on-demand recording featuring a leader in the field of mechanical circulatory support sharing his knowledge, expertise, and advice to Fellows as they move through training into practice.
Leslie Sweet, RN - Moderator Manager, MCS Publication Planning | Medical Affairs and Medical Sciences Mechanical Circulatory Support Medtronic US
Scott Silvestry, MD Surgical Director, Thoracic Transplant Programs Transplant Institute AdventHealth
U.S. Brief Statement: Medtronic HVAD System Indications For Use: The Medtronic HVAD System is indicated for hemodynamic support in patients with advanced, refractory left ventricular heart failure; either as a Bridge to Cardiac Transplantation (BTT), myocardial recovery, or as Destination Therapy(DT) in patients for whom subsequent transplantation is not planned. Contraindications: The HVAD System is contraindicated in patients who cannot tolerate anticoagulation therapy. Warnings/Precautions: Proper usage and maintenance of the HVAD System is critical for the functioning of the device. Serious and life-threatening adverse events, including stroke, have been associated with use of this device. Blood pressure management may reduce the risk of stroke. Never disconnect from two power sources at the same time (batteries or power adapters) since this will stop the pump, which could lead to serious injury or death. At least one power source must be connected at all times. Always keep a spare controller and fully charged spare batteries available at all times in case of an emergency. Do not disconnect the driveline from the controller or the pump will stop. Avoid devices and conditions that may induce strong static discharges as this may cause the VAD to perform improperly or stop. Magnetic resonance imaging (MRI) could cause harm to the patient or could cause the pump to stop. The HVAD Pump may cause interference with automatic implantable cardioverter-defibrillators (AICDs), which may lead to inappropriate shocks, arrhythmia and death. Chest compressions may pose a risk due to pump location and position of the outflow graft on the aorta -use clinical judgment. If chest compressions have been administered, confirm function and positioning of HVAD Pump post CPR. Potential Complications: Implantation of a VAD is an invasive procedure requiring general anesthesia and entry into the thoracic cavity. There are numerous known risks associated with this surgical procedure and the therapy including, but not limited to, death, stroke, neurological dysfunction, device malfunction, peripheral and device-related thromboembolic events, bleeding, right ventricular failure, infection, hemolysis and sepsis. Refer to the “Instructions for Use” for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions and potential adverse events prior to using this device. Caution: Federal law (USA) restricts these devices to sale by or on the order of a physician. Disclaimer:This content is provided for general educational purposes only and should not be considered the exclusive source for this type of information. This training does not replace or supersede approved labeling. The content will be shared with physicians and allied health professionals who seek a deeper understanding of the operation and use of Medtronic products and therapies with the intent of enhancing their knowledge of features and operations described in the HVAD System labeling. Patient information (names, serial numbers, date, etc.) has been changed or removed to protect the privacy of the patients used in this content. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in a particular situation. Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features and results may vary. Important Reminder This information is intended only for users in markets where Medtronic products and therapies are approved or available for use as indicated within the respective product manuals. Content on specific Medtronic products and therapies is not intended for users in markets that do not have authorization for use. Compensation This faculty is being paid as a consultant for the services being provided in accordance with applicable laws and regulations. UC Code UC202114377 EN Mhm. Mhm. Uh huh. Hello, everyone. My name is Leslie Sweet, and I am the manager for M. C s publication planning here at Medtronic M. C s. It's absolutely my pleasure and honor to welcome all of you today to the first in our series of live virtual symposium. As part of our M. C s fellows training and transition programs. We greatly appreciate you taking the time to join us today, especially considering how busy your schedules are and the diverse time zones that are represented here. We're very excited to welcome today Dr Scott Silvestri, a leader in the field of M. C s and the surgical director of the Thoracic transplant program at the Transplant Institute Advent Health in Orlando, Florida Dr. Sylvester will be sharing with us today his knowledge, expertise and insight for fellows transitioning from training into an attending position and NCs clinical practice the flow of the supposing Today we'll begin with Dr Silvestri walking us through the key steps and considerations to finding and securing the best M. C s program for you. As you establish your practice, his presentation will be followed by a question and answer session which will provide you an opportunity to ask him for his perspective and advice on your specific questions. This is really intended to be a very interactive discussion. So we encourage you strongly to take the opportunity to use that. Submit a question button on your webinar screen at any time, either during the presentation of the discussions so that we can be sure to add your question into the conversations with Dr Celestri. And finally, a recording of the symposium will be posted on the M. C s fellow space in the Medtronic Academy. So without further delay, it's absolutely my pleasure to turn over the symposium to Dr Scott Silvestri Scott. Thank you, Leslie. Welcome. I'd like to welcome all the mhm all the surgical fellows and attendings and, uh, who are here today to see this. And, uh, with that, I'm going to give you some homework. Uh, in addition to the submitted question, I'm gonna ask you to consider the most appropriate title for this. Uh, this talk and what I'd like to be chatting with you about is give you some experience with regards to what to do next. After learning how to be a bad surgeon, The next step is to find a place to be a bad surgeon and put your talents to work. This is all in the context of finishing training and also transitioning to practices of different flavor. And hopefully I can give you a little bit of a framework of how to approach these opportunities, whether it's in in this country or another country. Mhm. And of course, everything has been tweaked because in a post covid world, the process is different. The challenges are different and a lot of the aspects that we when we started training many times the circumstances are slightly different. All right, so residency is over. Now what do you do? You hit the road, you start looking around and you think now everything that I have waited for in my previous phase of life, which is up to 10 or 12 years for some of you is going to be different. What is it going to be and how is it going to be? And when you look at the opportunities, you have to ask yourself, what do you have to lose your choosing between two or three or four? Many of you five opportunities in different flavours. What is what is it that you're looking for? And what are the consequences of a decision that maybe, in retrospect, you you may or may not like Well, in general, all of the things that we face, what we offer is we're putting our time, and we're putting risk our risk and risk tolerance into the next phase. There are challenges of going into an established program with three or four people ahead of you. You will see that you will get in line for work challenges for starting your own program. You never have to get in line for work. But success or failure may depend on you and the input that you put in, which is time. So how do you find a job? Well, there are regular ways, and there were weird ways many people respond to advertisements. Uh, you can have face to face interviews there. I'm sorry. Yeah, response and advertisement. You can talk on the phone with the screening, you talk to people and the process comes up in, in fact, to, um, engage, acquire information, make a visit at some point and make a decision. Other ways to find a job will include asking your friends talking to the reps, working through industry. All of these ways help you make connections, and we'll talk about some of them. Well, the first question is always what kind of job. There are different jobs, and there are different jobs available, but they fall into a variety of buckets. You could be recruited to be a leader right out of fellowship or super fellowship. And in a leader, you have to have things that you may or may not have developed before, such as people, skills and negotiation. You may be a worker bee, and whereas there's enough work and they're splitting it up and you're all partners and you need to have the same skills or same competency as other people on your team, you may be a builder. And a builder is a special kind of job, because if you're building your own program, you have to understand not only the medicine and make good decisions, but you have to understand project management, change management and logistics. And for many of you, these are new skills, and then you maybe if you unfortunately get into a situation where you really just call Father. That is, there's really not enough work for everybody, but the people who are there are tired of taking call all the time. And so they split the call in order to have a lifestyle and in many circumstances, in some places, there's enough, uh, in the system. There's enough access in the system that they can afford to hire usually a young person and, uh, and have them enhance the lifestyle the time life benefit by taking call and trying to build a practice. It's generally recommended that if you see that circumstance, if you smell that, that's the circumstance that you try to avoid it because those tend to be more dead end jobs unless someone unexpectedly leaves, retires or gets ill. There's not likely to be a real upside to that When you look for opportunities, whether it's an M. C s program or M. C s transplant program or straight cardiac surgery job, there are different domains, and a lot of these domains include the location, which is very, very important. The work setting academic versus private practice versus community, urban etcetera. What's the work that you'll actually do? And we'll talk about that Who will you work with and who's going to either support you mentor, you bring you along or people who will be competing with you And it's not uncommon to get into a circumstance where it's the competition still exists between partners. That's probably not the best way to be. And then you look at the opportunity in, uh, in totality. And of course, we'd be remiss not to put in salary. But of all of these domains, probably salary is the one that's easiest, but the one that is off to the side because in general salaries will be arranged. And if the salary is very high, it probably tells you that there's more risk involved and the salary is very low. It tells you you're probably going to a very prestigious Northeastern University academic center, where they say congratulations. Welcome to our center, and you're making less than most of your friends do an internal medicine. So first you have to figure out what you want, and my advice is to you is be honest. If location is the most important thing, if you love windsurfing, if you love boating, don't look at jobs that are in the middle of the country that don't have lakes and don't allow you to do this If you are the kind of person who does well in a single specialty, multi specialty. Hmm, hospital based different areas have different pluses and minuses. If you if you are a practice, if you like working on your own than working in a large multi specialty practice, may not be for you. And then what is? The style is the style. You're going to five hospitals and you're basically running from six in the morning till 10 at night. Or is this style that you're going to do a couple of cases a day and you're going around and see consults with good support and then you'll work. Work ends at a reasonable hour and you'll go home. And then you'll have called one out of four a lot to be said for the leisure versus labor. No one is suggesting that you don't want to work or that you should work all the time, but you should know what your goals are and how it works. The infrastructure infrastructure is very important. You'll get a sense when you see how the people in the program are working, and what support level is there. Many programs, which are private practice or community based, have lien infrastructure, and the infrastructure is not like many of us are used to. Where there is a medical student, surgical resident, cardiac surgical resident and then a super fellow versus places that have one pa and the surgeon who are your partners, what do they like? Will they be helping you? Will they be disavowing all knowledge of your M. C s program? These are all very important things to develop. What is your budget? What do you need to earn for your needs? Obviously, if you already along in your life cycle and you have a spouse and Children, you need to have certain requirements for housing, schooling, etcetera, whereas if you have a large student loan burden or if you simply need to make more money to fuel your extravagant lifestyle. These are things which, by being honest and examining and writing on a piece of paper to help figure out where is best for you and what you need and what your asks are, it's not surprising that most decisions are based on location preferences the color here represents density for population. And you can see this was a change in population from 19 92,000, according to the U. S. Census. And you can see that there's a sort of a sucking sound of the people here and lower density going to the sun, the u of the sun and you can see down in Florida where 23 Texas, 20 Arizona, 40 California, Nevada, certainly less. And you can get an idea of what the population density is. And that also tells you one where you might find jobs but to also where it might be very competitive in those markets. So not only once you find a job there, what does it look like once you're there? Well, how do you find the opportunity? Many of you are already working towards that very good ways to find it. Uh, send a letter of, uh, letter of interest to the areas of interest practices of interest and programs. It never hurts. If you grew up in Boston to send a letter about a year before you need a job to places that might be interested in your expertise, might be interested in having you there. And certainly if you have ties to an area or if you have ties to a practice, it is always will bring you in. And people who are committed to the area are very different than people who are just visiting. So if you grew up in Des Moines and you want to go home, they know the people looking there, that you're serious about your interests there, that it's not because you couldn't find opportunities in other potentially more attractive to other people areas. Similarly, I got to, uh, look at a job recently in a hospital that I actually saw a heart surgery for the first time as a freshman in college, and that was a very neat thing for me to come full circle and to look at a program to come back as a leader in the program, potentially in an area that I had grown up grown up in. And I remembered some of the people in the names, and that was a very, very good experience, and if you have connections like that, you should use them to help you see where you might go. You want to connect with people you want to connect as much as possible. If you have, uh, faculty or colleagues or trainees who are ahead of you who went to areas that you like or places use these connections very often, it's easy to come by and say to a chief in the program, he said. I might need a faculty member say, Well, I'm going to be home or I'm going to be visiting the area. Would it be possible to come by and have a talk? Anything that you can do to differentiate yourself from an email and a C V P D. F. Will help you become a real person. And that will often often allow people to work a little bit harder to get the position posted to meet your time frame. And I'll tell you this that we've learned the best jobs are made. They're not advertised and making connections early. Many practices will plan well in advance. The jobs that you make so the job that you have and the job that you ultimately make it into our reflection of the interaction between the needs of a hospital or practice your skills and your success, and the longer you stick around and the more value you show as you transition in your surgical lifecycle, the more likely you are to make the job into an amazing job that you'd be very happy. Keeping the job that you have when you take a job isn't always the same job that you have when you're in the job. And so I came to Advent. Health was Florida Hospital, then in 2015 after leaving Washoe, and the job that I came for was a smaller program practice leader. The job that I have now is director of thoracic transplant and co director of the Cardiovascular Institute and Shock and ECMO and a bunch of other things. But the point is, you don't stay in the same job even if you show up as the new person. You won't be the new person long, and hopefully you won't always be the most junior partner in that setting. Ask others to connect for you, so if you have trainees, friends, brothers, relatives, faculty people in other fields, ask them if they could ask their surgeons if they're looking or will be looking because most jobs aren't posted, and I think that's very important as my mentor used to say to me, The million dollar a year job in Carmel by the sea is taken, and it's not likely to be available soon, And it was ironic because I actually interviewed in Carmel by the sea for a job. It certainly wasn't a million dollars, and it certainly wasn't a great job. But somebody has to have these jobs. You have to be honest, because what about your family? And if you don't have one, will you want one? What does support look like? What about your significant other's professional, social religious? These are all important factors for many of us, and maybe even not, if not at that moment in time that you're looking for a job, it may become more important later. And so sometimes houses of worship, sometimes interests and hobbies factor in that really make one area or one practice much more desirable. Cost of living will factor in as well the presence or absence of things like state income, tax, schools, childcare, cultural hobbies and interests. And very often, if you're looking with another professional and you're looking to relocate, making a list in cataloging these pluses and minuses for different opportunities is very important and will help you make the right decision for you. The setting the setting is important. What is a safe harbor? Are the people in the practice are? Do they look out after their team? Is the group collegial? Do they get along? Evaluate the other groups in town? So you're looking at a cardiac surgery in a in a town with three valid programs and seven heart surgery groups? What does that look like? And are you in the good group, or are you in the group that people don't think is as good these can factor in? Don't rely on what your group says about themselves with the other group. Read between the lines and ask around. Certainly all of us have connections in our community, in different areas. And you can ask, I want to live in Boston. What is the group outside of Boston at this location? Like and what are they thought of? Well, the people downtown think they're terrible, but the people in town think they're they're really good. So these are things which are worth checking out, and remember that a practice is like a suit. What is the good practice or a good practice for one of us may not be a great practice for someone else, and that goes back to fit. So the suit fits for you. It's great. But if it doesn't fit, no matter how much they're offering you or how little they're offering you at times, just pass. What's it like? So you get a call and we're looking for a person and we try to call everyone back or screening and seeing if people will meet your needs. When you get a phone call, you have a you make a phone call to, uh to someone in the group, remember, they're going to be evaluating a lot of intangibles about what you say. There are a lot of very well qualified people. Be honest, be interested. Listen, I used to say, and I think I still do that. The more the interviewee talks during an interview, the more impressed they'll be with you. The interview. The more the interviewer talks, the more they will be impressed. But you can prod them along, and you can ask questions to get the information. Uh, time frame is important. What are the needs What do they say the needs are? What do you assess? The needs? Uh, the first call is generally not the time to talk money. It's generally not the time to ask how much call there is or things like that. Um, you can talk work life balance. But it's not necessarily the time for the exact equations. And if you're clearly not interested, if you're clearly not interested in being in the middle of the country, you absolutely, positively wanna be in California, you absolutely want to be in Chicago, then b honest and upfront, say, I think this is a tremendous practice, and if I were looking in this area, I would be very interested in coming out there. But I'm not really considering these areas. And then many, many, many, many people simply shift blame to their spouse. And they say, my spouse wants to be near her family, whereas her family, her family, is everywhere but Iowa. And therefore I'm not looking in Iowa, however, always consider that there's places that have a need. Offer the best jobs after a telephone interview. If you're interested, send a note, sent an email, send a text highlight some aspect of it. Thank you, Doctor Celestri, for talking to me about Orlando. It sounds like in the place I'm sorry that Disney is not really offering as many slots for people as they had before. However, it still is an interesting place. You have a high volume program. Let me know how you would like to continue this conversation, that kind of thing. So we invite you for a visit, you get invited. This is a fit visit. This is the first Look. This is telling you trying to see whether you will fit in with the group. You need to go with a list of questions to see if you like the area. If you've never been there, uh, then it's maybe the first time you've experienced what the people are like, what the region is like, what the cost of living in is. Do you like the partners? You may like one person in the group, The person you talk to on the phone. Very often, many practices put the most affable, most charming person to reach out and call people. But what about the rest of them is your partner that everybody seems to think is a little bit of trouble. And do they like you? What about the hospital? How supportive. What is the relationship? Real estate agent? Collect phone numbers and email, collect business cards and then also, if you're really interested, one way of showing interest or signaling interest is saying to the most person you are most similar to Or maybe the youngest partner in age, my significant other may have some questions. Is it all right if he or she reaches out to your significant other to know what it's like to live here? And very often those kind of connections are very meaningful and will help a transition. Here is a very important question that you should be actively looking for with active questions and effort. What will I actually be doing? I see myself as a heart surgeon. I'm gonna be doing 200 cabbages, 100 and 50 valves and 50 VADs 20 transplants a year. Well, is that what they really need and how will you get there? What resources are they willing to put in there? What is your support and what do the stakeholders say about this and you learn to read the language very very importantly to know when stakeholders seem frustrated. When people use the term they instead of us, they're signaling you about how people feel about the institutions or practices that they are part of. After you visit, send another note. Thank people, especially on the hospital side, if you're interested, declare so you're not saying you're 100% going to come there. But if you are interested or you're mildly interested, say I remain interested in your position, if not thank people for their time. And you can simply say I thank you for your time. I really enjoyed my ability to visit you in Orlando. You seem to have a committed program. However, I have several other opportunities that I am choosing from. And I do not think that I would be moving forward with recruitment to Orlando because my family wants to be in the Northeast. It's all good. No one's going to take offense, but it's very good because the people with the maturity and communication skills to say politely I'm not interested will save everybody time and everybody knows that. That's the most precious thing that we have, especially in cardiac surgery, because time is limited. Well, you go when you visit again at the second visit. Or, as I say, second date, they're signaling you. We like you. You may be down to one or two other other candidates, and they want to get another look and extended fashion. It also signals that you like them, that you are considering this opportunity. I always say to applicants and and fellows, when they ask, if you don't like the job, that is, if they are for you a job at reasonable terms and a reasonable salary and a friendly contract and we'll talk about that later, would you take it? If you wouldn't take it? You shouldn't go on that visit. Generally in the academic setting, you can expect that you will sit at the end of the second visit, whether it's a day or two days or three days with the decider, it's usually the chair of surgery. It could be the chair of a cardiothoracic surgery department or division or section, and they will ask you what you need, whether you are interested, whether you would be considered whether you would consider this this program, and so you should have a good idea before that four o'clock visit with Dr Jones at the end, whether you're yes or no and what you might need, because people will ask you, this is the most challenging circumstance because many of us are not comfortable talking about money. Many of us aren't comfortable asserting ourselves in a polite way and anything else that you need in terms of information or support. That's the time to bring it up. I would be interested in your program, Dr Jones. But to be honest, I've talked to several of your partners and they can't stand you. Well, you probably shouldn't be that honest, but you should be able to say whether you'd be interested. And don't say yes if you're not. If you already have another job and you went there because you were considering it. But at the end of the visit, it really isn't the place you want to be. Be direct, my top 10 questions, and then I give you a little bit more questions about what you should be asking to find out information. I will say this in general when someone asks you if you have any more questions. If you say no, then the interview is in essence ending. But if you say no, you're also saying of all the things in all of the information and all the interactions, I don't really need your unique opinion. And so I would always say, Save a question for the end, Save a question when you're sitting with the profusion ist and he says, Is there anything else you'd like to know? And some of those questions are really, really easy, and we'll get there. Um, why do you like working here? Some of those questions are What's the best thing about this program? Tell me about your favorite moment in this program while you've been here. Any of those are personal interest based and will open up the opportunity for whoever you're sitting with to provide you with information that may be useful. And those are the kind of questions that will help you make decisions because many of these decisions, despite my questions here, which are content based, are more feeling based and you'll get a better sense of who the team is and why they're there. You should leave a second interview with an idea of who am I working for and who's yes matters. And that's important because if you're building a program are starting a program and you're not entering into an established M. C s program or other, you have to know where you're going for support. Who's checking labs at 8 p.m. Who's doing the teaching on Saturday when you want to consent a bad patient for an evaluation? Are you doing it? Who's coming in? What about clinical trials? Are you? Do you have support and research for clinical trials? We all know that the next great bad is always coming up first in the clinical trial. And if you can't be in that trial, then you're not going to hang out with your friends and all the cool kids. And more than that, if the program next door across town is in the trial, they will assert a lot of innovation and, uh, state of the art over your program. And that's a very bad feeling. So these are things which I think you should know, and you should try to know who am I working for and whose yes matters. So, aside from the content based interview questions, these are some things that you can if you want to take a screenshot and look at this. These are the questions that will differentiate you when you're on an interview or you're at the end of the second tiring day and you really just want to go back. Close your eyes, check Facebook and listen to some music. But these are the things to pull out instead. Doctor, what does success look like for me? If I were to come here, what are the markers of success? How would you consider this hire a good higher? What are you going to look for? Alternatively, what are your concerns with this higher interviewing? An applicant recently was asked about, um, the positive side. And what are the concerns? And my concerns are based on the assumptions I am going to bring someone in here that I will be responsible for, and my concern is the assumption that business will continue as usual is based on the volume that will have and that that's not going to happen. I always worry about that, because the people we bring we are responsible for, and if the assumptions don't work, it's not just their salary or their work. It's your word and it's you're bringing them there with the promise of business. Another important question. Where is the support for this position? Does it exist? Will we be hiring? Are we going to be borrowing from other team members of the programs? And is this a shared resource? Is this something I will get after everyone is done? Am I splitting the P A in the operating room with the chief? And he's going to have the he she is going to have their help 98% of the time, and I can I'm free to use them whenever they're not using them between the hours of seven and three. Yeah, it's a challenge, so you should have a clear idea of where your support is coming from. Mentorship. You know, as much as we think we're finished when we leave our training, it's a lifelong pursuit, and the first several years are very important to help us prevent missteps. No matter what we think, we don't know everything. We will need help, and senior partners are usually established very often. They've been in that neighborhood in that area for a long time, and a kind word from a senior partner to a cardiology, referring that everything was fine, can stop damage, were in bad case Goes sideways, and that's important. Or, as I've learned for a colleague, harsh word from a chair to a cardiologist can sink you. And if that is the case, it's certainly better to know that earlier rather than later. And we always say it's harder to be a good partner than a good spouse. There is no love and usually a lot more money involved. And so the manners can be different. And I'll let you let you digest that for a little bit. Well, in the M. C s world, those of us who have a passion for mechanical secretary support, durable and acute. What is the structure? Is it a freestanding program? Is that a new program, historical volumes? Infrastructure, which we talked about delegating cases important? How do cases get decided? When do I get my bad cases? Is it the cardiologist calls me up directly, or do they call the senior person all the time? What is my transplant responsibility and how How do I get free rein within the program to do what comes my way? These are important. How do we handle cases that come in on call? And very often it's important to ask the more junior members of the team what happens and how it works. Well, the other simple solution is just build your own program, and then you get to do everything that comes your way. And that represents a trade off the trade off in the value In a standalone program, especially those of you who have been in high volume or medium volume places, there's less surgeons, A new program. It could be competitive, but it's It's most often in private practice, but you don't have to share as much, and you will enjoy the fruits of your labor. If you develop good relationships and good quality with cardiologists in the area and primary care doctors, then those values that you work will come to you. Well, what about places that are a bad slash transplant program? Many times of the the positions you're looking at? A really the soldier positions, not the chief positions. They have more surgeons for more call, they're generally established. They may be low volume, and they're not bringing you in to bring the volume up. And generally speaking, it's an academic practice. Remember that no program stays the same in terms of its volume. But many places that have challenges and our low volume, either due to population density, quality, referrals or skill tend to stay low volume until something else happens. And generally speaking, those are places that you may want to not be the recruit. For your first job. You may come in and be the Rainmaker or the problem solver or the fixer. Those are jobs, but those usually aren't jobs right out of training. It is important because we overestimate when you go to a place what you can do in one year, and we underestimate what we can achieve in five years. And I will tell you that when I came to Florida, I really wanted to make a splash on the bad world. And honestly, we underperform in Florida and we have continued to underperform. Over the course of five years, we've built volumes and we've built a program with lateral support and multidimensional, and last year we were the fifth largest heart transplant program in the country, So we went from doing five transplants a year to the fifth largest. And so take your successes, bring people along, don't outstrip your blood supply. If we were to have grown that level in one year, it would not be sustainable. Nor would it be something that I think we would have been proud of in terms of quality and value and quality is the most important aspect that we bring to our medical practice. Yeah, ask yourself this question. When I did a leadership course at Wash U in the business in the business school, they asked us, What is your strategic value proposition? What does that mean? It means, what do I offer my practice or program that other people offer differently or don't offer? And what am I going to add to the practice program every day? You need to know what your ad is, because when you go and talk to people when you're interviewing and when you ask for a certain salary, are you a superstar? Are you going to bring them super small incisions, Robotic VADs like Zane Copy? Or are you going to be someone who is going to work and provide a capacity and volume? Those different value propositions have different value to programs in different desirability. Intractability. You want to be the value add to the program that it needs, and that's finding the right program. And that's very important because when you interview and you look at these positions, if you're really good at what you do, but you like having a senior partner around, it's probably not the best way to start a program. By the same token, if you feel you have really, really mastered almost everything in M. C s, then go out on your own and bet on yourself with a new program, as long as you have appropriate support and you can have that dialogue very well. Lastly, when you finally get to this, it is really about the money you can talk about call. You can't talk about vacation. You can't talk about coverage and workload. All of those things are important. All of those things have a value, but it does come down to what is the salary going to be for you and for those works and what are what is the pay? And each of these things have to have an established value, and you can find them. How do you get paid the most common form of payment for cardiac surgeons in the M. C s world, starting out is a guarantee, and it's usually a modest guarantee. It may be several $100 that may go up to almost a half a million dollars, depending where you are and what you'll do. If you don't have a productivity based component, there is still an inherent productivity assumption in it. And so that's very important to know. And you can value any salary by dividing by approximately $60. And that's your work. RV you calculation And that's your work units. And so if someone is going to give you an insane salary, there's going to be inherently an assumption at some point that there's productivity that will be had so you can have a productivity based. You can have a mix between a guarantee and a productivity, and so productivity might be a number of cases. It might be a number of days worked. It usually is work RV use, and many of the the beginning contracts will have a guarantee for the first two years, and then in the third year, they transition where you can either get the guarantee, or you can have a bonus, and the bonus can be based on things like quality. The bonus can be based on things like good citizenship, doing your charts and the rest. But there will be something in there that, based on productivity, will its growth or quality. What will you get in terms of assistance in building the volume? Is it a sink or swim at atmosphere? Or is it the junior part? The senior partner is going to bring the junior around, introduce him to the cardiologist, transition him and scrub with him on difficult cases, him or her, and then work towards building their practice. Is it a practice where there's partnership? Is it a practice that you have to buy in when and how much? These are all things which people talk about. These are all things which you should be able to ask and get information. If you ask. How does one determine whether there will be a partner and the person interviewing you says, Well, we figure it out later on and see how the person does it should be transparent. It should be clear, and it should be consistent. The partner ahead of you should have got partnership based on the same amount volume, time and quality that they're considering for you. And you should have a good idea. Um, you should have a very good idea of what that is and how you're going to achieve it again. That question. What does success look like? And how will you know that I am successful here? Malpractice is important because malpractices an equation. If you go and take a job and you don't like the job after a year or two, if you leave, do you have to pay a tail malpractices covered based on either when the occurrence happened or when someone files suit? Occurrence. Malpractice is most common in academic medical centers, and that is you have malpractice for this academic year. If something happens, no matter when it comes up five years down the road, seven years down the road, or longer, even though things time out, it wasn't disclosed. They found out about it. Occurrence do not require a tail claims made state if you have a malpractice and you have in an ongoing fashion insurance malpractice insurance. If you have a claim made today that they'll cover it when the malpractices enforced. But if you leave town the claims made next year and you no longer have it, you're out of luck and that you need something called detail. Obviously, someone who is a new starting surgeon would not have an occurrence or claims made in the first 3 to 6 months, or even the first 1 to 2 years, because any malpractice usually takes at least that to come out to be filed to go through and so claims made is exceptionally inexpensive. The claims made policy, for example, in the state of Michigan when I was practicing might have been $60,000 for the entire year, whereas when I transitioned to Philadelphia and the current policy with a state subsidized reduction for someone with no claims, no history simply for cardiac surgeon was about $375,000 a year. Tremendous difference. And if you leave Philadelphia and you had a claims made and you had to have a tail that might have cost you about $100,000 now most new grads, one or two years into their job don't have an extra $100,000 that they want to hand over to an insurance company for a piece of paper to cover a malpractice tail, and that's important. So in the contract and in use discussions, how is malpractice covered? And what happens if someone leaves? Obviously, if you're not going to a job thinking that you're going to leave later, but you might. And that's why it's important to know my best advice about contracts is have it looked at not by your college buddy, not by, uh, uncle who's good at this, but by a non relative, you'll pay them for it. You'll pay up to $500 to have a first contract looked at. It's best evaluated by a medical contract lawyer, employment lawyer, and you get what you pay for when you look at it. I had a phenomenal attorney, looked at my first contract, and she made sure that I was protected in a variety of ways. And later, when I transitioned out of my first job, I was grateful for all of the advice that she gave me that I paid for. But I was grateful for the advice because the contract was very favorably slanted towards me and my interests. Secondly, when you have things that you like to have changed in the contract, you get a sense for the environment and the practice. When they tell you I'm sorry. This is a boilerplate. We can't change everything, anything, rather. And this is the contract. Well, that kind of tells you how the relationship is going to go now. I will say there is a middle ground, most academic medical centers. You will get a letter of interest or a letter of terms, and they will say we will provide a BNC and then the real meat of an academic contract are usually the faculty by laws and the things that you look in faculty bylaws for our. When does each academic rank need to be notified of non renewal? For example, my first academic job. If you're an assistant, they could not renew your contract and give you three months notice. When you made associate or full professor, they had to give you one year notice of non renewal. Now anyone can get fired at any time in any job if there's what they call its cause. But many contracts have not for cause termination as little as 3 to 6 months, which means they may not. You may have done a great job, but they decided that they just can't afford you anymore. And if they release you or terminate your contract not for cause, that you're really all they're going to give you is maybe three months worth of salary, that's probably not the best circumstance to be and as a first job. And if you have a three month contract termination for cause language, you really have a continuously renewing three month contract. It's not a five year contract. It's not. A one year contract is not a two year contract. If you can be discharged in a contract for not for cause, that is for no reason, and depending on the state you're in, then it's really a very short contract. And that's important. To realize a contract is a resuscitation of a verbally agreed upon terms. Hearing someone say Dr Jones, I would never do that and you say Well, if you would never do that and we agree that that's not something you would do, let's just make sure we put it in the contract because if it isn't in the contract. It may get done, but it doesn't have to. Now, a word about support. Yeah. If someone promises to bring your program along and says we will definitely get this support for you to VAT coordinators, we will get, uh, an engineer. We will stock VADs on the shelf. We will do all these things. Many of those things don't belong in the contract, but can be resuscitated in an email or a letter or a memorandum of understanding. Obviously, you would never sue or leave a job because they only put your non favorite vat on the shelf and wouldn't put two brands of ads or the par was low. But you might. If you have a unique request, you may want to have them put it in the contract or verbally agree, and then put it in an email. Thank you, Dr Jones. I enjoyed my time visiting with you, especially of interest, was the fact that you were supportive of having the new hardware device and participating in the clinical trial. Although there will be capital costs if your significant other asks you Where is that contract? I'm sorry if you ask your significant other where do I put my contract? You're probably already in trouble. Many times when parties deviate from a signed contract, they do so without concern that you will have to sue in order to get remedy. And that's the challenge. It's always better to negotiate something and get agreement than it is to try to get a lawyer, write a letter and see how it works. Lastly, examining your contract more than once a week is assigned to look for a new job. Rocky Daily told me this when I was interviewing at the Mayo Clinic when I finished training, he said, Don't drift is that institutions need their own needs. You may want to be a micro valve surgeon, and you take a job at a prestigious place, and there are five micro valve surgeons in front of you, and they tell you we need someone to do coronaries and open, reduce and do these other things, and you start doing it at the end of five years. You're no longer a microsurgeon. You're an opener or closer your coronary surgeon you haven't touched of add in four years, and you really don't know what's going on in the field. because you've been so busy humping it in the operating room for the needs of the institution, every relationship should be mutually beneficial and Rocky daily. Telling me not to drift was probably some of the best advice I ever got in my life. Although there are things that I've done to help institutions because of need and being a good citizen, I will tell you that if you have a five year plan to become the best microsurgeon in the region or the best M. C s program in the region, don't shortchange that ambition in that goal by consuming your time with things that aren't going to get you there. And that's probably the best I could give you. So you have your first job. Just acknowledge that there will be others. No choice is irreversible. Stay in touch with your network, whether it's mentors, peers, training institutions, et cetera. Uh, there are places, and there are practices that are merry. Go rounds where people keep getting on and off, and you should pick up on that before you get there. But just remember, if you get there and you're not exactly happy and you're not happy for reasons which are particular to that job, that institution that practice environment. Don't be afraid to make a change. If, however, you are not satisfied because of things which are inherent in surgery. Call getting phone calls from the transfer center getting calls from referring doctors that don't really know what we do or getting calls from families about, uh, family members, patient family members who are upset with the care they're getting, then those aren't things which are intrinsic to any environment. Those are things which are intrinsic to a lot of what we do in cardiac surgery and specifically transplant M. C s. And so understand what makes you happy, what doesn't and when you get the feedback from your environment incorporated in a way that helps you achieve that satisfaction and happiness. Lastly, as you go out there and you put these principles into practice, honesty with your aspirations, fears and goals is the best tool that you have to find the right position for you. There aren't perfect positions, but there are positions where you will thrive. You will be supported, you will grow and you will become all that you wanted to do and work hard to be. But if you're honest with what that is and what your goals are and what's important and what matters and what doesn't matter, that's going to help you find it. And that's probably the most important advice I can give you in this whole aspect of becoming an M. C. S surgeon. Thank you very much. Thanks very much, Dr Sylvester. That was incredible. A very comprehensive review of the process. There are so many important components and so many things to think about That was a great step by step guide to work through the process and to do so successfully. Um, so I'm going to We've received some questions. And so I'm going to, uh in the time that we have left, try to work through some of these questions that we were. We have received. This one's kind of interesting. I have I haven't taken any business courses during my college career, and I'm concerned that I'm joining a practice that really is a business. So what do you recommend that I do too booster in my business acumen. Yeah. So there this is a a stepwise approach. You need to learn about first medicine and insurance and and how medicine is funded. There are some good books, many of them available online resellers looking at the business of medicine in basics, uh, the other way to figure it out After you have your first job and a lot of the ways that I learned, a lot of the things I know was sit down with your business manager and spend some time with the business manager. And in an academic practice, we had a phenomenal one at Washoe and other places and understand how the business of medicine works, where the revenue comes from, what the expenses are, how you can optimize revenue, the things that you can do to help control your environment and also understand the mechanism. It does a lot of ways go back to risk in time, and so a lot of the things that you are going to do an M. C s will be revenue generating. Some of them are not. And so the question is always, How much time do you have and where can you spend it? You don't need to know a lot about the business of medicine to be a young physician in a practice, but you should keep your eyes open and learn as you go. It's a lot to get through. Um, if I write a letter that I'm not interested to a program, so you go for an interview or write a letter that I'm not interested, but my situation changes. Is it still appropriate to return to the previous centre clinicians to reinstate the interest? Or is that bridge well burned? I would say that in general there are a lot of candidates today and that it would be a hard sell once you say you're not interested. More honest, answer. Uh, if you want to consider that program is I've just started my, uh, interviewing process. I am interested. There are aspects of your program or practice that I would be very much interested in. But I'd like to take the time or my spouse significant. Other would like me to take the time to explore some other options as well in different geographic areas. May I return to this, or do you need an answer now? And that leaves the door open in a very polite way? Uh, if you go to someone and say no, I would never really want to work here. And then you have to go back. It's awkward, to say the least. Yeah, no, that's great advice. Great advice on that. Do you think that covid. Has supported the hiring process? In other words, are people still hiring as they were, or more programs stepping back, putting things on hold our more seasoned positions retiring sooner? Maybe, then later. What is your thought about the infamous covid impact? The answer is yes. Okay, all of the above, in all the ways, in some places, it's enhanced. In other places. It has hurt. Um, it depends on the environment. I would say that in many places they have put off hiring for one or two years because of covid, depending on their labor force and concerns over volume in other places, it has accelerated the need. Older physicians may have gotten covid and are not returning. Older physicians may have decided that they don't want to practice any longer. It's not worth the risk, and they're not getting the same thing out of it. The good news is 2021. The demographics of cardiac surgery have never been more favorable to the new graduate and that there should be a selection of jobs for the new graduates. Something like 29% of the cardiac surgery workforce currently is over age 60 which means, if you position yourself well in an area, whether it's a domain academic, cardiac surgery or an area. FORT Lauderdale, Florida New York City, At least the third of the cardiac surgeons that you're contending within 2021 will not still be practicing in 2026 2027 2028. And so, as you're coming into your own with your full set of skills and as you're maturing in your skills as an in practice cardiac surgeon, there will be tremendous opportunities and many people will be dropping off. And so this is one of those opportunities where transitioning and practice of being the junior partner So nica Chuckas is a world famous, uh, aortic surgeon that I overlapped with in in ST Louis, and he brought junior partners in, and then he seemed to outlast them. And so the trick is timing because the last one was the one that actually inherited his practice, and the last one is very, very talented. Is doing a phenomenal job. And so you have to assess that In each individual practice, setting many places, hospitals have lost money or volume. Other places like New York businesses back. My friends, they're telling me that the volumes are up and they're just the same. And so they, if they were on track to need someone, they're going to need someone. And then, of course, keep your ears to the ground. Use your industry, use your friends. Use your network because as you're looking for a job, you're all locked and loaded to go to program A. And then all of a sudden the surgeon is leaving from this place to go to Austin, Texas, and that has created an opportunity in a place that maybe it was your first choice, whether it's New York City or Boston or Cleveland, wherever it is. That opportunity is something that then people will have an accelerated time time frame for, because they don't want to miss the opportunity to get someone on this go round. Great. Thank you. I can't believe we're at the top of the hour, but we actually are. So, um, I wanna on behalf of everyone. Thank you very much, Doctor Silvestri, for your time and for the valuable information insight that you shared with us today. Both in your presentation discussions. It's just been great and very insightful. Um, And to those of you who have joined us today in our audience, we thank you again for joining us and participating in this symposium and the discussions. As we mentioned at the start of this session, there will be a recording of this symposium that will be made available on the M. C s fellow space in Medtronic Academy, where you can also find important announcements about other upcoming events that we have scheduled. We welcome your feedback regarding this symposium in the survey that you will receive following the program. And again, thank you so much for taking the time. Thanks. Thanks, Scott. Really appreciate. Thank you. Good evening. Mhm. Mhm. Mhm. Mhm. Mm. Mhm. Yeah. Mhm.