ASGBI_2_careers_10.17.24

Hello, and welcome to behind the knife today. We're back with our awesome ASGBI collaborators from the UK for another installment of the ASGBI collaborative series, where we compare and contrast various aspects of the field of surgery as it is done in Great Britain and the United States. After hearing from both the US and the UK based experts, you as the listeners get to decide who does it better.

I'm John Williams, one of the BTK fellows. And once again, I'm joined by Kelly Bateman and Jared Volgamit from the UK. To host an awesome episode for you guys, Kelly, do you want to talk about what topic we're going to talk about today? Today, we'll be talking about surgeons careers in both the UK and the US.

Specifically, we'll compare and contrast some of the different types of hospital environments, practice types, a bit of general versus specialty care, private versus public care, finding a surgical job, hours and compensation, and much, much more. And obviously, to talk about all these things, we need two experts who have seen

very illustrious and varied careers.

Jared, would you like to introduce our UK expert guest? Today we're joined by Dr. Christian Makutovic, who is the President elect of the Association of Surgeons of Great Britain and Ireland. He is a general and HPV surgeon in Manchester, England. And he completed a bachelor's of science in biochemistry at the University of Birmingham before studying medicine at the University of Manchester.

He received an M. D. doctorate at the University of Manchester for research into sepsis, and he underwent surgical training in the Northwest Deanery in England. He then completed his HPB and liver transplant fellowship in Leeds, and he's been a consultant surgeon in Nottingham, Leeds, and most recently in Manchester since 2018.

He also works privately at Spire Manchester Hospital. It's an absolute pleasure to welcome Dr. Mikutovic to Behind the Knife. Thank you very much, everybody. Lovely to be here. All right. And from the United States side,

we have Dr. Scott Steele, well known to the Behind the Knife podcast. Of course, he's the president of the Cleveland Clinic Main Campus and the chair of the Department of Colorectal Surgery there.

Dr. Steele graduated from West Point and then received his medical degree from the University of Wisconsin. He then underwent general surgery residency training at Madigan Army Medical Center in Tacoma, followed by colorectal surgery fellowship training at the University of Minnesota. Dr. Steele then served in the military as an active duty surgeon until 2015, including multiple deployments and further faculty time at Madigan, where he additionally served as associate program director for general surgery.

He then served as division chief of colorectal surgery at university hospitals in Cleveland and the associate director of surgical services at the Digestive Health Institute prior to being named chair of the Department of Colorectal Surgery. At the Cleveland clinic back in 2016, a position that he continues to hold today.

Like I mentioned, Dr. Steele is also a founding member of behind the knife and therefore my boss. Thanks Dr. Steele for taking the time. Yeah. Great to be here and great to have everybody.

So before we get started, I think it might be helpful just to get a general lay of the land of the healthcare landscape in both the United States and the UK, particularly how there are factors that might relate to surgeons as they're entering the workforce.

So if both of you don't mind just giving us a broad overview of the health system in the UK, maybe starting with you, Dr. Mikutovic. Once you've all gone through your residency training, you finally get your attending job. And I think we're going to touch on how we get those later in life. Most. Most attendings or consultants, as we are known in the UK work in an NHS hospital.

And that means that you are working in a public hospital where you are paid exactly the same as any attending, doing whatever specialty you're doing, whether that's general medicine general surgery, cardiothoracic surgery, or dermatology, we're all paid the same.

Most patients are eligible for NHS care, and so we have an unselected number of patients that come through the door, and we have to treat everybody exactly the same.

So that's our main job that I would say the majority of. Attendings or consultants do day to day, then a subset of people also want to do private work and private work are are undertaken in smaller private hospitals that don't have an emergency department and don't do any emergency work.

So it's very much cold, benign elective work from hernias and gallbladders. All the way up to bowel resections and cardiac surgery. So, I would say a good 10 to 20 percent of the consultants in a hospital would do private work. But for us, it's done in our own time. So evenings, weekends, and

days off.

So this is not, this is a completely separate contract to what we normally do. And that's what we do in the UK. Yeah, so in the U. S. I would say it's a little bit different. And so you may have heard of a lot of the different institutions, academic medical centers, whether it be Cleveland Clinic, Duke, Mayo, you name it.

There's so many different academic university medical centers. But the reality is, is that there is a dichotomy between those academic centers and the community hospitals of private practice. So actually, the majority of surgical care is actually doesn't happen in the academic centers. It happens in private practice.

There's certainly hybrid. States where somebody has split jobs, part of the time they're in private practice, part of the time they're in some of the academic medical centers or conversely, some of our private practitioners will have residents or trainees, medical students that will actually rotate with them.

So they get that feel for teaching and have that feel for doing academics. But by and large, those are the two chunks like myself. I was in the U. S. Military. I want some time. And

so there's that whole military side of it as well. Yeah. that you can jump into. And, you know, when you think about it, there's fundamental differences in how you divide your time.

I know we're going to get a little bit into that about different settings. The so called, you know, if you want to call them pillars, if you're going to be a primary clinician, if you're going to be a surgical scientist, if you're going to, you know, be a hardcore basic science researcher, all of that is, and along with this also comes in differences as pay as well as some of the compensation structure.

And it's great timing because All you BTK listeners can go back just a little bit. We had a four part series that we just went through the differences in compensation and structure and pay. And I encourage everybody to listen to that four part series on BTK and that it's also differences in clinical resources.

And I, I think that, you know, depending on what you want to do, depending on what you want to go into complexity of care, bread and butter, a little bit of mixture of both really goes into the heart of what you want to be able to do. And then in addition to that. Of course, the states are big, and certain

people may want to work in a rural setting, or they may want to work in a city, or they may want to work close to home, and so that kind of also is layered into that choice to say how you're going to get into that work setting for surgeons.

Okay that's brilliant. Let's say that I'm a surgeon. Fresh out of training. Extremely green. How do I go about finding my first job? And when it comes to the job search, what do you feel are some important things to consider? And what do you think are some must knows when interviewing for your first job?

I think I get to go first here. So again, I'm going to go ahead and plug our own BTK course, because we do cover a lot of this within finding your first jobs, things you can ask for things you wouldn't necessarily think that you can ask for. So it does depend a little bit about academic versus private in the type of practice that you have.

So for example, if you're going to join an academic medical center, you may have those conversations that the, you know, your future boss may say, I'm looking

for you to, I'm a colorectal surgeon. You are going to do pelvic floor or you're going to do X, Y, Z, whatever that is. And you're going to know where your place is.

And when you're looking at your contract, it may be extremely boiler plates and outside of a number that may be a salary or maybe a little bit of the time that you have allotted for one thing or another. For example, maybe you're somebody that has a skill set in AI and with AI growing, you might have dedicated time to that.

Those conversations are going to ongo versus joining a busy private practice where what you do is take care of patients 24 seven or five days a week, or depending on what your FTE is. I know we're going to go into that a little bit later that that's going to make a determination about what you do.

So some of the things you need to consider, I mentioned it before. Are you in a social circumstance that you may say, I need to be in a certain location, whether it be family that have medical problems or job things that you have to say, I need to go into this aspect, but it also may be the, you know, how you have what you're looking

for in practice.

Are you looking to be a part of a big group? Do you want a very small group? You know, the days of having a solo practitioner and hanging out your shell out there and saying, I'm going to just go to work for my own. They're limited. And so finding your job is largely through informal networking in the States, you know, most people either practice with somebody or they're going to stay at the same institution in some cases that they trained at, or they may know somebody back home that they went off the train and then they're going to go back to where they grew up in.

So, you know, what you should say and or be able to must knows when interviewing your job. Understand what it is really you're being asked to do. There's, you know, I'm always surprised if you, if you think about it in the States upwards, and I've seen these numbers I don't know exactly what it is now, but upwards of 50 percent of people may change jobs within two years of their first job, let that sink in.

That's a huge loss for not only you, but it's a huge loss for the organization that's trying to hire you as you're trying to

build in. So, you know, you got to get board certified in that time, you know, you can look at what's the call look like, what is the opportunities, you know, if let's just say that you're, you know, a woman out there that wants to children went to the first two years, how does that work?

Can you be a part time and then come back to work or stay out at part time? These are the things that, you know, you may know you want to be able to bring up. You know, when you're also thinking about it, you know, what is the type of practice that you're going to do? Again, I talked about this before. If you're somebody that wants to take care of redo pouches, then to go into a busy private practice may not be the thing for you.

If you're somebody that wants to have dedicated time associated with research, you got to want to be able to talk about that. Other things that you want to ask for, and we're going to go into a little bit about compensation, is What is that compensation model again, I encourage you to listen to the last series that we had.

Is it grow over time? Does it stay stagnant? Is there certain targets? Not only targets in terms of productivity, but in terms of quality that are nowadays are talked into compensation and baked in there. So those are

the questions you wanna be able to ask. If you think about it, if you go to a certain job.

For one person, because you really want to work with that person. Are they going to stay there? And what are you going to do if they leave? I can tell you from personal experience, I give this lecture sometimes is that my first job out of the military. My boss left my second job out of the military. My boss left after I got this position, my boss left.

So what's the take home message? Don't hire me if you're a boss or you may be able to find yourself somewhere else. So you gotta think about all these things. As you go into that first job. Wow. How'd you follow that? So it's slightly different in the UK. So, we have a very well trodden path in how you apply for consultants jobs and it's through a national advertising scheme.

So anybody in the whole of the UK can apply for any job that doesn't mean that they will get that job. You are eligible to

apply for any job. And I think before you make a decision on. What job you want to apply for, you have very similar discussion about, do you want to be in a university academic medical center?

Do you want to be in a district general hospital, which is a, a smaller district hospital that can still have over a thousand beds, but not affiliated with the university. Most academic medical centers are also trauma centers. So, it has a difference in your future life depending on whether you want to work in a trauma center or a district general hospital.

And then, we're a small island. We're not as big as the U. S. So, but we still do have Rural hospitals in Fort William, up in the Highlands of Scotland some smaller ones in Wales. So, and they have attractions, and people do want to work in these places. So, that's the first

question Jared, that you have to think about.

Where do you want to work? And then in terms of finding out it's a little bit of word of mouth, very much like the U. S. system. So if you have worked in that institution before, you've got on, you've enjoyed your colleagues, then that puts you in a very good stead to be shortlisted and go for interview and maybe get the job.

But if you haven't worked there before, then there's a very structured way of investigating the place. So, you go and visit the institution. Let's say I want a job in, In Cardiff, you go and visit Cardiff and you visit the clinical director or the chief of surgery. You make inquiries with other members of the team and try to get a feel for what they need.

This is not a time to sell yourself. This is a time to find out What they need and very similar to Dr. Steele they may want a

pelvic floor person. They may want somebody who can spearhead robotics. So it's important when you first look at jobs that you find out what they need. And if it's something completely different to what you can offer, then at least, you know, that you're unlikely to fit in and The best departments are the ones where you fit in and you are not fighting with somebody else who's got exactly the same remit as you.

So find a department where you fit in and you're not treading on any toes in doing anything. So often units will have a researcher academic, they'll have an educationalist, They'll have somebody who's into management and will want to do the the managerial aspect and the operational side of Practice then you'll have somebody who just wants to cut just wants to do the work and I call That

person the doer and every department needs a doer.

They're the person that you go to to say Hey, buddy we've got five gallbladders. They're about to breach. We need an extra list on a weekend. And this person will go, yep, sign me up and they'll do it. And then there's a fifth type of person, which I always call the Cristiano Ronaldo person of a unit.

And these are the exceptional people that don't really fit into one particular mold. Now these can be. Amazing people to work with, or they can be incredibly disruptive to a unit. And one unit works and one unit fights a lot. And these Cristiano Ronaldo figures. are very difficult to control. And if you are one, then that's, it's an interesting thing that you have, but if you are managing one as I have done, it's, it can be very difficult.

So they're the type of people that go into consultant life. And

then in, in terms of getting a job in the UK, it's very structured. You'll have a Royal College representative who will ask you about your CV. You'll have the medical director of the entire hospital who will ask you about quality governance and will make sure that you know how to refer patients appropriately and behavior is appropriate.

You'll have your normal line manager will ask about local unit knowledge and what they need. And then obviously you have your new colleagues who will usually talk to you about some clinical scenario where. they will want you to eventually ask for help and call for advice. So that's usually what happens.

Most units will appoint you as a substantive, which is a consultant that is there permanently. Some will try before they can buy and that's called a locum consultant job. I did one of those. It's a very useful one year to cut your teeth as a

consultant. And for a unit to see if you fit in. So that's generally how things go in the UK.

All right. Excellent. Well, it certainly sounds like there's quite a bit to consider when searching for your first surgeon job, whether it be the U S or the UK. I think, you know, considering that your job is still just a fraction of your life, even though as surgeons, it seems like it's the entire thing.

I'd love to hear more about how work and life mingle in both the U S and the UK for surgeons. Could both of you maybe take us through how a standard week to week is structured? How's your time partitioned? What's a relatively typical call structure and how do surgeons establish a balance between the demands of your job and other aspects of their lives?

Yeah, I think I'll jump in first and, and as we've talked a little bit about before, it really depends on the type of practice you're at, right? And so take for example, that if you join a busy private practice, you may every single one of your days of your work week may be all clinical and depending

on your type of practice, whether you do endoscopy, whether you see clinic, whether you see ORs, if you have dedicated or some people divide their days in halves, think about the work week in the U S about FTE.

So an FTE is essentially one FTE is a five day work week. So if you think about it at 0. 2 for every day, so if you're a 0. 8 clinical, that means you've got a day that you're doing something else. Most people, and especially in the beginning of their careers, oftentimes are a one FTE, meaning that all five of their days, or maybe they have a half day of admin, or maybe they have some dedicated research time.

If you have an academic practice that you're going to get into that. So. Yeah. determining how that goes. Work life balance is is not a term. It's really work life integration, as most people say, because, you know, especially when you're busy, it's you have to be able to say, you know, I'm going to be available and building a practice is you know, is a part of the deal.

As you go along, we're talking about surgical careers, definitely with this audience, we're probably talking about early surgical

careers and that's much different, but your career is going to evolve. I think about my own career. When I first started out, granted, I was in the military and employed and you did other things like that.

But as president of, you know, main campus at Cleveland Clinic, my work week is a lot different than it used to be when I was a department chair. And it's a lot different than it was when I was a, early staff surgeon. And so to understand that and understand where your goals are in the type of practice that you get into is going to do that.

So for example most recently I'll operate on Mondays and Thursdays. I may see clinic on Tuesdays as you scope on Fridays. And I have some admin time on Wednesdays and maybe a third, a Friday afternoon to be able to take care of an apartment or a a hospital, something like that. That's a lot different than somebody who is going to be.

compensated on a different type of a practice that they may say, I'm going to operate three days a week. I'm going to see clinic two days a week. And you know, sometimes my clinic goes in the middle of the night on Wednesday, so I can provide after hours care. So you have to

understand what that means kind of along those lines as well.

The other thing that you need to be able to think about is, you know, You know, what type of practice do you want to have and who do you want to be? And you know, I knew that I wanted a job eventually like I have right now. So to be able to say, I'm going to set up my practice to the point where I want to be have a very busy clinical practice that focused on reoperative surgery and I want to do academics.

So when I'm early, I want to do some research and do all that. That may affect kind of what you do with your quote unquote free time. I will tell you that there's in terms of call, you asked a little bit about a question about a call and that varies. It also varies at the stage of your career. You may be in a practice of two and you split every other week, but the call may not be that that busy that you're seeing, you know, if you're in a rural place in the United States.

Conversely, if you're in an academic medical center and there's five of you, then you may be on call once a week. And so that really does depend. And it goes back to the points of determining when you're seeking out jobs. That's a common question. You

know, what's call like, what am I expected to do? And then there's variations within the hospital system as well.

For example, if you're a specialty surgeon, if you're HBB or colorectal or something along that lines, do you have to take general surgery call? Do you have to take trauma call? Is it in house trauma call? I was a colorectal surgeon, but I took trauma call for 17 years. I took emergency general surgery and trauma call.

You may not want to be able to do that. So to understand it's not just the. Number of call days you have, it's also the type of call that you have. So kind of putting that, all that stuff together and understanding that in addition, you may be a mom or a dad or a husband or a wife and all of those things, you need to work into that work life integration.

And for some people, honestly, I tell some of my staff, I say, you may need to put onto your calendars date night or, or time with your kids. And I know that sounds ridiculous, but. Man, mission creep, as we used to say in the military, or work creep always gets in. You're going to

find out that not only you are a busy clinical surgeon, but you're also going to be the safety officer, the quality officer.

You're going to have all these other things that you're like, wait a minute. When I first joined my practice in the military, one of the very first things they said is, Hey, we got a grant to you know, to renovate our operating rooms and you're going to be the lead person on it. I had no idea what that meant.

I was like, what are you talking about? Like, I don't, I don't, I don't know anything about that. And so, you know, get these type of projects come out. It was a great project by the way, and it probably spurred some of the interest that I have from terms of operations and getting my MBA eventually, but you may not know what hits you in any type of practice.

So keep that in mind. That's, that's really interesting. I think my own path echoes something very similar. So when you first start in the UK, Absolutely the same. You want to be busy. You want to be one FTE. So the The timing of a consultant day is split into four hour blocks in the UK called programmed

activities.

So every, every day, every eight hour a day is two programmed activities. Now that doesn't mean we're in for eight hours. We're often in a lot longer, but that's how our pay structure is. And majority of consultants are paid 10 PAs. When they start, but they often take on so many more roles that they go up to 12.

And I would say the average consultant does gets paid for 12 programmed activities, and that's 48 hours. So the minimum that we work is 48 hours. And I would say the majority of my colleagues are in or doing stuff for 60 plus hours. And that in itself doesn't seem very fair because we're not remunerated for.

A lot of the things that we do extra and that's one of the drawbacks. I think in the NHS is because we're not remunerated to do all this extra work. A lot of people won't do it because there isn't much incentive to do that anyway. So programmed activity

is for our block. And in that, in the working week, I will go through my working week so that you, you can get a feel for it.

But in a working week, you'll have ward round, you'll have operating room you'll have endoscopy clinic. And then you'll have a dedicated admin time, but also a time for MDT and any other meetings that you have. So that's how our fee structure is broken down. Most attendings will have half a day or even a full day.

to do private work. So they will then go to point eight of an FTE. And that is then their, their private day on that week. So my, my working week starts on a Monday, Monday morning, I take the dog for a walk. So I'm not I'm not in at work, but in the afternoon, I do the medical leadership forum, which is our medical leaders group of the hospital followed by my admin session.

Tuesday, I have two and a

half session theater list at the main hospital. Wednesday morning is MDT Wednesday afternoon. I've got what we call is supporting professional activity, SPA. And that is a minimum requirement from our general medical council so that you do your mandatory training, you do CPD and you do appraisal and revalidation so that you keep your registration.

So that's a, a minimum thing that, that we have in the UK. So a bit like your board certification but you have to keep renewing it every five years. And so that's part of our job plan. Thursday for me is my private day. And I go to the local private hospital and do hernias and gallbladders, nothing exciting.

Friday is my other big clinical day. So I do a grand round in the morning and then clinic all afternoon. And that's my working week. Our on call is very similar to the U S you, you

may have a small district general hospital with five or seven consultant colleagues, and then you'll be a one in five or one in seven, but your take probably won't be as busy.

As a city center, academic medical center like ours, where we take a trauma, we have vascular intervention. So we have a lot of vascular paths coming with dead bowel. We're also the local area for any embolization. So we get a lot of patients transferred over. So our encore can be quite busy and they could be very complex patients.

And so thankfully there's 13 of us on the rota. So you're only one uncle, one in 13. And that has a real difference in your, your quality of life and your work life integration in terms of, The on call frequency really does affect for me, it affects my mood of that day.

It can affect home life, and I've come from a pancreas resectional job in Leeds where it was 1 in 7.

To a job here in Manchester where it's one in 13 and I cannot tell you how different that is on your intensity work life Balance and your mood when you get home. So anyway, it's a real important thing to think about you want to be busy In your first few years, you want to be the person that people go to because Christian's always available.

Christian will do that gallbladder. There's an extra case. Christian always says yes. And you want to be that yes person where people will hunt you down and give you extra work. Because that is a reputation that is good to cultivate. If you've got it, you pretty much have it for the rest of your career.

But if you don't make, if you don't get that impression, if you don't make that first impression in your first few years, it's really difficult to

make it in subsequent years because somebody else will be that go to person. So I've gone through my typical week. We've gone through my. On call that's basically what happens in a UK hospital.

I think that was a good summary. I wonder if, yeah, both of you sort of can say based on your experiences and sort of illustrious careers what do you think real builds prestige in the surgical community, you know, as aspiring surgeons, we all dream of being the rock stars of surgery and how do you find that balance within your lives?

See it develop so that you feel that you've had a fulfilling surgical career. So I think it's very fair to say that the majority of us will not be rock stars, but that's not a bad thing. I don't think I'm a rock star. I'm just a budding surgeon who happens to take opportunities as they arise and it's important that you do

your best.

So how do you build prestige? So. In the UK there are certain different ways that you can build prestige. If you want to be an academic then obviously publishing lots, recruiting to randomize trials and becoming a collaborator, collaborator with multiple units to build your research portfolio. And that your name and your prestige will go with what you publish.

And there's a saying in the UK that academic surgeons, you publish or you perish. I don't know if you get that in the US, but certainly in the UK, unless you're publishing, you're not doing anything. And if you're an academic, then you're really on a sticky wicket if you are not publishing.

Educationalists. So if you want to be an educationalist and get prestige, then you go up into the university or the training programs, the deaneries that we get, and you can become head of school, or you can become a national figure in education and

training. In terms of management or leadership, then you can, you start the ball rolling by taking on leadership roles in your hospital.

And if you find that you're good with people or you're good at getting people to work together and and all sim from the same hit sheet then you can go into association and national roles and I guess that that's where I've suddenly found myself it's not something I ever thought I would end up doing is be becoming the president of the biggest surgical association in the UK.

You'd have told me that five years ago, I would have laughed and said that you're being silly. So you just have to go with it. And it's really important that you enjoy What you do and feel fulfilled in what you're doing. The last one is the the prestige of being somebody who's invented an operation, or you're just

mega amazing at doing robotics.

And these, I think are the rock stars that you're thinking about the amazing so in, in HPB, you've got your your Mark Besselings, you've got your, Daniel Shirky, you've got your Henri Bismuth, all the famous people that have got names and procedures after them. Let's face it. The majority of us are not going to become rock stars and there's never going to be a Makutovich procedure because no one will ever spell it.

That's where it, where it UK. Yeah, so I don't, I don't have too much more to add beside what Christian said, although I do look forward to the Makutovich type procedure, that would be great. I would just say, I would take this question and go a step up and say, how do you define success? You know, traditionally in an academic medical center, they talk about the trifecta of success being the clinician, The education expert and the research, right?

That's the trifecta in surgery. It's, you know, the surgical

trifecta, you know, so what defines success for you may not be successful for somebody else. And this is where you just need to do you, you need to know yourself. You know, if you consider, especially if you're earlier in your career, one of the biggest things is we've been told, you know, when you're applying for medical school, you're applying for surgical residency or there you're applying for fellowship, you know, like, you know, what do you want to do in life?

And everybody, it's almost like road. Oh, I want to be an academic surgeon. Do you? And what does that mean? I always ask people when I ask that question to answer it, I'm like, What does that mean? What is an academic surgeon? And is it what you really want to do? Because I'm looking at their CV and it doesn't look like that.

And there's nothing wrong with being a busy clinical surgeon. You want to just take care of patients who want to operate. And so the Christian spelled out extremely well of all the different opportunities that you have, whether you go into research or you go into innovation, or you go into a national presence or an international global presence.

If you would have told me, Way back in the day that a kid from northern

Wisconsin would travel the world, literally travel the world. Speaking about colorectal surgery, I thought you're crazy. If you were to tell me, you know, in 2015, when I left the military, that I'd be president of the Cleveland Clinic, I would have also said you were crazy.

And the reality is, is that the nice thing about surgery is there are multiple opportunities to reinvent yourself. Or to change pathways at different stages of your career and still being able to I'm still operate despite my job right now because I like to operate. It's it's a breath of fresh air sometimes.

And so understanding what you want out of your career is incredibly important. And it may not be the road answer that you were so in tune to be able to say or even felt like you needed to do to get to the next step of being what you wanted to be. And there's nothing wrong with. Being able to do basic science or being an innovator or being an administrator or being you know, we didn't even talk about, you know, we have certain surgeons that go into the legislative tarpon and work on policy and look at the bigger picture.

The

nice thing is, is that you can actually affect patients lives and your fellow caregivers lives in many different ways, despite how you're doing. And so. understanding yourself and also understanding how your feelings about certain professions are are likely to and may very well change over time. You may say, Oh my God, that guy's a suit.

And one day you might find yourself in as a quote unquote suit in doing administrative things when they never would have appealed to you earlier in your career. So, that's, that's the neat thing about surgery. It's the neat thing about what we do. We can still take care of patients. We can still have an impact to patients and we can still look for opportunities to do dual things at the same time.

We all know there's, you know, people out there that are doing, you know, part time lab and part time clinical or part time admin or part time this, and you can fit it all in. So. Great question. That's great. Some very wise and inspiring words, I think, to take us through our careers. I guess one of the big differences between the UK and

the US is obviously our wages and money.

And I think that's something we should talk about. Do you think that money defines success following on from our conversation? And I guess, how does the pay structure work in your countries? Dr. Steele, do you want to go first? Yeah, so, does pay define success? Maybe to some people it does. Maybe there's somebody out there that defines themselves by the type of watch they wear, or the type of car they have, or something like that, that it defines success.

Certainly there's, there, there, there may be people out there that define it that. I think most of us would say no, but I would also say, conversely, on the flip side, pay is important, and to sit there and think that it doesn't, I think we're kidding ourselves, and I know that there is this kind of taboo, if you will, to talk about pay when you're going into jobs, and as a chair, I would tell you that that was always one of the first things that there's kind of in the U.

S. Oftentimes it's when you're looking for jobs or you're looking to recruit people. The first thing is a little bit like just

coffee or just lunch. You don't really talk about pay and maybe you'll touch on it. The second visit, man, I try to talk about it early and try to give a ballpark range. What are you looking for?

What can we offer you? Because there's nothing, it's a waste of time. If you're expecting to make 600, 000 a year, and I'm going to start you at 300, 000, we are not matching. And so, you know, it's a waste of everybody's time to be able to go into that. And so those were the conversations that I experienced when I was actually interviewing for jobs and I'm like, wow, are you kidding me?

Like that, that that's not even remotely close to another one. And we try to act and, you know, like our time is extremely valuable. And again, I'm going to make a plug. We cover this exact same thing in a four part series and BTK talking about what you're worth. To go into this thing. Do not be ashamed to bring up pay, but also understand that you may be looking for a job where you're going to be boiler plated into that, that everybody starts at a certain salary and go from there in the U S military.

I, I didn't, you don't

make much money at all. I mean, I lived it for. Many, many, many years, and I still had an absolutely fulfilling career in the military and it was amazing and it did not define success for me, but I also moonlighted a lot on the weekends doing trauma so I could make extra money so we could go on a trip and take my daughter to Disney World and do all the things that maybe I wouldn't have been able to do.

And, and, and for whatever reason, and I don't know if it's the ethos of medicine or just what's pumped into us, but we feel guilty about asking for a pay raise, or we feel guilty about. Feeling that we kind of want some nice things too, especially earlier in their career. And there's nothing wrong with that.

So no, it does not define success, but also conversely, there is nothing wrong with understanding pay, understanding where you want to think about this. So I run with two private equity guys and they are starting their ability to have wealth generation and not wealth, meaning I'm going to be rich. I mean, just money.

You're making money at

such an earlier stage that we do as surgeons. Think about the fact that most of you listening to this podcast will have probably spent more time after high school in education or training than before high school. Think about that. You'd even start earning some realistic salaries for what you do until you're in your early 30s in some cases.

That's, that's pretty amazing. And so, don't be ashamed of it. Understand it, but also understand it necessarily does not define you. So I completely agree with the money not being the definition of success. So in, in the UK, it's very different. Everybody starts on the same salary when you get your first attending job and that's a starting salary of 78, 000 pounds.

And then that's for a 10 PA, 10 programmed activity job. And then it goes up incrementally Transcribed over 19 years to 125 or I think it

might be even higher now that the consultants have agreed a higher pace Richard. So let's face it, You're not going to be poor. You're going to be in the top one to 2 percent of the population in the UK.

So you're never really going to be poor, but you're just not going to be mega rich. And I don't think any of us went into this profession to become mega rich. If you did, then you should really have gone into business. In terms of UK pay structure, it does go up really quickly. And you're on over 100, 000 quite quickly.

Depending on how much private practice you do, you could double that or even triple that, depending on what specialty you're in and how much time you give to private practice. So, if you're very money driven and you want lots of nice things and You, you want to have a big house and an Aston

Martin and you want to do loads of private practice.

Our profession allows that. If however, you, you think a hundred thousand pounds is more than enough. Thank you very much. And you want to spend more time at home or with children or traveling. Then that's absolutely fine as well. The more administrative or clinical lead jobs that you do also come with a responsibility premium.

So as you go higher up in an organization, I think very similar to the U S if you're the chief of surgery, you get a responsibility allowance, you get a bigger pay. So, you're never going to be poor. You're just not going to be mega rich. Well, thank you very much, both of you for sharing your perspectives.

It certainly seems that your respective careers have been extremely fulfilling. Both in the public sector and in the military and a bit in the private sector. I've certainly learned a lot for all those listeners who still feel a bit wet behind the ears

when it comes to thinking about how they put their first foot forward.

Do you have any words of wisdom for early career surgeons or trainees expecting to enter the surgical workforce in the next two or three years that you haven't already mentioned anything perhaps that someone said to you before you started? And that's stuck with you. I just say I've got one that that's stuck in my mind.

And it was a A liver surgeon or HPV surgeon in North Manchester general called David Sherlock, who I absolutely adored and loved working for him. And he said to me, Christian a new consultant should be seen and not heard for the first two years. Keep your head down. Don't put your head above the parapet.

And after two years you can start having an opinion. And that really means. Keeping your head down, being the person that you're in the hospital all the time, build that relationship, build that reputation that you are the go to person. And after a

couple of years where you've learned how to conduct yourself, you've learned how to behave amongst peers who are now your consultant or attending colleagues, then you can start to Voice and opinion and I that stuck with me and I've used that every single time I've gone to a new job because I think the people that I have subsequently seen in later life when I've been the chief of surgery, the young consultants who come in a bit like a bull through a gate and wanting this wanting that and haven't put the work in.

tend not to do very well in those first two years. So for me, that's, that stuck with me and seemed very sensible. Yeah, I, I would say four quick things. The first thing is, is that just be aware that you never know Who is in your circle at your time that will affect your life one day, either on the positive or negative side, the amount of times where

even my own personal history, one of the residents that was a ER doc that I absolutely could not stand as a resident.

I wound up being and he hated me more and he probably should have. Turned out to be my roommate when I was on one of my deployments. And to this day is one of my best friends. As a matter of fact, as somebody that on all my major decisions in life, I will call and you just don't know. And you have a different relationship or somebody who you don't like, who may be your boss one day.

So. Watch how you depart and see if that's the case. And the second thing is to keep all doors open. You don't understand, you know, when you say no to something that may be great for you, but you know, you might find something. I gave the example earlier of when I was charged with renovating. Oh, I didn't know anything about money.

I didn't know anything about operationalization of things. I didn't know a whole lot. And, but you keep doors open. Did I think that one day at age 44, I would go back and get my MBA? No, I had no idea, but. Keep the doors open and then you can decide what do you want to. And when you want to go through something, blow through it.

The third thing I would say is that at the end of the day as surgeons, no matter what, and Christian said it very, very eloquently through several times during this podcast you're a surgeon and you will be defined by your patient outcomes. So regardless of all the other things that you want to do, take great care of patients, have great outcomes, ask for help.

Load the boat being able to say that you're going to be defined by surgeons. First and foremost, that's what you are until you decide that you're not going to be able to do that. And then finally a little bit of insight. You guys may not know this, but everybody on the BTK listeners that we talk about dominate the day and everything like that.

But where that came from is that is my own personal life model. I've been saying it forever and it's not meant to put somebody down or do whatever, whatever. It's just to Take advantage of every day and realize what a special place we have, that we get to one, take care of patients at their absolute most vulnerable time in life.

When they are naked on a table, maybe having cancer out of absolute

no control at all. And they put all of their trust in us to do the right things for them. I tell a trainees, there is no more intimate relationship you can have than two. Cut into another person's body and never forget what an honor and what respect we need to be able to have to be able to do that.

Thank you both so much. I think not just for the career advice but the life advice in general. I think you've both sort of provided that light at the end of the tunnel for us busy surgical trainees and residents. That, you know, that we can have really fulfilling careers. I think to sort of try and summarise some of, you know, consultants in the UK.

I think we have quite a regulated system, quite a structured system. It's variations between hospital, but we all know how the NHS works. We know that we've got our Royal Colleges that will support us as we get our initial consultancy job. I think you've both sort of reiterated the

importance of those first two years of getting a good foundation, making sure you know your team that you're getting involved with, that you're offering the right things to the department and you settle into that department and find out what works for you.

And then as you say, once you've got some operating, some experience under your belt then you can start to explore some of the various opportunities within research, academia, education, management, and innovation. I still I still can't help, but think back to the Mikutovich procedure that needs to be invented.

You know, I had a, I had an attending once tell me as a resident that if you find yourself in a situation where you're doing an operation, you've never heard of before. Stop doing it because it's probably not the right thing to do. So, but now I know that I can call it the procedure and that's okay. So, in the U.

S. side of things, there's quite a bit of variability in terms of the environment in which you work in, whether it be academic versus private institutions, urban versus rural settings and so many other different ways to slice it. And a lot of your job search and career

discovery should take into account what's important to you and your individual situation.

That includes things like the style of practice you want, the resources that will be at your disposal, both clinically and non clinically, and personal and family needs, of course, as well. The week to week might involve over the course of your career, and it probably will, depending on your individual responsibilities.

It's important to integrate those demands of your work and life together. Success is something that's defined by the individual and, and certainly it's something that you should reflect upon for yourself. And there's a multitude of ways in which you can make an impact as a surgeon, both in the patient care space primarily, but also in broader circles as well.

The key is finding what pathway is right for you. Well, that concludes another excellent episode of our ASGBI collaborative series. For all the listeners out there, I hope that you enjoy listening about surgeon careers in the UK and the US as much as we did talking about it. There certainly seems to be some similarities among the differences, so you can decide for yourself who does it better.

Thank you so much, Dr. Mikutovic and Dr. Steele for taking the time with us and for sharing your expert insights. We really, really appreciate it. For the listeners out there, if you have any thoughts, comments, or suggestions, please feel free to reach out to us at hello at behind the knife dot org. Dr.

Mikulovic, I know Dr. Steele gave us the original, but do you mind doing the honors to end the episode? Until next time, dominate the day.