Grand Rounds-How to Choose a Practice and Succeed: The Essentials, Pearls and Pitfalls

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- Hello, my name is Troy Payner. I am a neurosurgeon with Goodman Campbell Brain and Spine. I have the pleasure of presenting to you today, the first in a series of discussions, directed at residents who are seeking a job in neurosurgery, looking at their employment options. And today we have the pleasure of Dr. Bill Couldwell leading us off in this discussion on how to choose a practice. Well, Bill, welcome.

- Thanks, Troy. It's a pleasure to be here and a pleasure to discuss this topic. So we'd like to just start off by giving an overview of some of the elements that have go into choosing a practice and to start off with, I have no disclosures to state in. Troy, I understand you have royalty from Stryker, but I don't think either one of us have any disclosures relevant to this topic.

- Correct.

- So let's talk about private practice versus academics, which is the major decision, I think most residents face. And it's really dependent on the individual. I had a friend of mine who is a heart surgeon who used to say to me, you know, people end up doing what they want to do. And I think that's very true. And I think you need to weigh a number of considerations when you think about what type of job you wish to pursue. There's some overlap between the paradigms. They're not really mutually exclusive. And there's a number of programs around the country that's a hybrid of paradigms, we call these privademics for short. And an excellent example is the Goodman Campbell Brain and Spine, where Troy works, the Barrow Neurological Institute, the Peoria group in Illinois, and the New York Medical College Department, where I used to work in Westchester, New York. And these may include members of the group that are purely in academics and some that are purely in private practice. And maybe Troy, you can comment a little bit on how the Goodman Campbell Brain and Spine group works.

- So we are a true merger of a historically private practice that was already somewhat privademic, but merged with the Indiana University Department of Neurosurgery. So we took what most would consider a pure academic practice and a pure private practice, and actually merged them into one. And it has worked very well for us, but it took a lot of work to figure out how to make it work. And that would be a whole presentation on itself that I will do, but it is what you call privademic. We truly are a hybrid of a University Department of Neurosurgery and a true private practice.

- Thanks, Troy. So what are the pros of a private practice? Well, these again are my personal observations over my career. It's easier to choose where you want to live because there's many more opportunities in private practice at community hospitals than there are at academic medical centers. There's more variety of practice opportunities. And the practice may be limited in scope. And this may be an advantage you may want to limit your practice to mostly spine surgery or for instance, or degenerative spine surgery. You may want to limit it to trauma. The case mix index may be lower, which may be an advantage for you in that you're not dealing with most complicated cases and less patients in the ICU, et cetera. And there's often better reimbursement. So what about the cons of a private practice? Well, again, the practice may be limited in scope, and I'll talk more about this shortly, but you may find it harder to do the spectrum of complex cranial surgery and private practice that you were used to in your training program. The case mix index therefore, maybe lower. The night call may be worse because you'll be doing call primarily on your own as the first line. And you maybe making in covering more ERs. There's less academic interest in the environment. And then there'll be a need to negotiate for institutional support for call, et cetera. Now the antitrust issues are an important one in private practice because the hospitals can't be perceived as paying neurosurgeons to bring their cases and do business there. So there are other ways that they can support neurosurgery such as medical directorships, call pay, et cetera. And there's less ancillary support for complex cases in most of the community hospitals. Troy, would you like to make some comments about these?

- Yeah, so I think you've, I'm sorry, I think you have highlighted the, the major pros and cons. I think in private practice, there's a greater expectation on the individual's productivity, earning your way, literally. You have to generate revenue in order to be compensated. And as you'll talk in the academic practice, there may be more costs shifting, but, than there is in a private practice.

- Right?

- So there's a little more pressure in private practice to produce.

- Okay. So let's talk about academic practice. So the pros as I see them, are that you can develop a sub-specialty and you can limit your practice to specific areas and become an expert in that area. You can pursue academic interests, which may include clinical or basic science research in allied areas. And there are many basic science research capabilities and resources around you, especially in a large academic medical center. There's often several different departments you can collaborate with and develop research programs with. There's usually better ancillary services. Now I say that, because it obviously some of the private practices and large ones in the country have superb ancillary services, but in general, most academic medical centers without higher level neuro-radiology support, endovascular support, ICU support, et cetera, because they're used to having higher volumes of those types of patients. And the night call may be easier because you obviously have buffer with house staff. And so what about the cons of academic practice? So you may perceive that subspecialty development is a con in so far as that you may have interest in being a general, broad practitioner in doing spine and cranial work, et cetera. In most larger academic medical practices, there's pressure for people to sub-specialize and to limit their practice, and then hence become an expert in that specific area. Their academic interests compete with patient care, so that it's hard to do research in addition to your patient care responsibilities. And we've all witnessed over our careers, an increase in volume and emphasis on patient care in our views, even in academic practices. There's often less geographical choice, in that the academic medical centers are often in larger metropolitan areas. So there's less opportunity to live exactly where you want live. And you may need subspecialty training before somebody offers you a specific job in an academic medical center that you wish to pursue. There'll be academic expectations. There's the tenure and promotions committee, and there's often a five-year or six-year limit where you're expected to produce a certain number of papers, obtain extramural funding, get a research program started, et cetera, or you won't be promoted. And in general, the reimbursement is less than a private practice job. So by the Volkswagen. Troy?

- So I think that's fair, but I think when people are considering private practice versus academics, particularly when you're looking at salary and how much you're going to be paid, I think it's more important that people understand what it is they like to do. And if you are a neurosurgeon, you are going to do well, but the market perhaps somewhat arbitrarily, but for whatever reason that we can't change the market rewards right now, spine surgery, the most, and brain surgery, second highest, and maybe pediatric neurosurgery, third highest, and the PhD in the lab is going to be making the lowest. So if you are wanting to do lab research, I don't think it's fair that you can expect to be paid or insist on being paid like a spine surgeon, because the market determines what it's worth. But if your passion is to do research, then you should still do it. And you should pursue that because you shouldn't be just motivated by the money, you will still do well. You just won't do as well as a full-time private practice spine surgeon. That's what the market determines. So you have to figure out what it is that motivates you and what your passions are, and then make a decision based on that.

- Thanks, Troy. And I think it's worth emphasizing that you're right, we all do very well. And it's just that the way the system is structured, it's hard to expect the same reimbursement if you're going to take significant time and spend on your research career and not do clinical work, because the system just doesn't have enough resources to support the research work at the same effort as clinical work. So when choosing a private practice job, I think the question is how many partners? And there's been a definite trend. And I think Troy can attest to this, that the private groups have amalgamated in many cases. The Indiana group is the exact example of this. But call coverage, for instance, it's much easier when you have a larger group versus also the complexity, because often a larger group may cover several different hospitals. When you're just starting out in your private practice, it's great to have senior partners around, a big brother or sister, that's an expert in a specific case. So the difficult case comes in, you can run it by them, get their advice, get their assistance, if you needed it. It's a tremendous appeal to have a larger group with experienced people that can help the younger people get going. There's managed care and hospital negotiations, and there'll be maybe duplication, especially interest, such that if you're interested in the vascular practice, there's more than one vascular specialists that can help you take call and so you're not specifically taking calls such as pediatric call or vascular call every night. And then there's geographical coverage consideration. That means there may be several hospitals over a larger area, and you may be required to drive greater distances between those hospitals. Troy, would you like to make any comments?

- So it has long been known that there is power in numbers and for all these things listed, the larger your group is, the more neurosurgeons in the group applying neurosurgery to that, the easier all of these things are going to be. You're going to have more ability to cover call with more people that will dilute the demand for call over greater number in each individual will have less of it. There will be more guidance from senior partners when you're just starting. You will have more clout to negotiate these contracts. The duplication of specialties is an advantage to you so that you're not the only one doing things. And you do have senior experts that can guide you. And your ability to cover a larger geographical area is enhanced by your size. So that's really I think, what's driving smaller groups to try to consolidate, and they clearly are the advantages as listed here.

- Thanks, Troy. And just to, for the record, I mean, Troy's overseeing the amalgamation of this large group in Indiana, which represents really the best of merging of a practice of both private practice and academic group covering a large area. So he speaks from a direct experience. Now, the institution, is it a trauma center? This is a major issue for your quality of life. Is there a busy ER? This can be a pro or con. This could keep you up at night, but it could also feed you with the kind of cases that you'd like to do, like subarachnoid hemorrhages. Is there a good ancillary coverage? Radiology is a big one, neurology, critical care, general surgery. It's also important to know what they expect from you so that there's no misconception down the line about what your responsibilities were, and how much you were supposed to deliver to the hospital. And what are the capabilities of that particular hospitals OR? Do they have the equipment necessary for you to do what you need to do? So, I'll just speak with you on personal experience, because I actually started my career off at LA County Hospital and I was on staff for many years, doing a skull base and vascular practice, and then went out with my best friend, who was a spine surgeon, and into a practice in private practice in North Dakota, where we covered Minot and Bismarck. And what was very hobbyist to me in a short period of time, was that there was such a completely different spectrum of what the community was used to taking care of in that environment, compared to what we just assume is a daily occurrence in a major academic medical center. So if you have a complicated aneurysm, for instance, it's difficult for them sometimes to deal with that, to understand the nature of what we're trying to do. And it's beyond, it's beyond the capabilities of a lot of the ancillary services. So if you have a complex skull-based tumor, for example, do you have ENT support to help you with this? Do you have ophthalmology? And then even things as simple as a skull-base meningioma. Well, the only meningiomas that are often seen in these smaller community hospitals are done there, are simple convexity meningiomas. So they're just not used to having a sick patient with cranial nerve palsy post-operatively in the ICU. So there's a difference in expectation and what they believe is the outcome from meningioma surgery, versus what you know is the outcome from a difficult skull-based meningioma. So, I think this is all news to be taken into account when you think about moving into a community practice. So,

- I might add- please, Troy, make a comment.

- I was just going to say, even if you are the world's brightest surgeon, if you do cases beyond the capacity of that hospital, and when I say that hospital, I mean the, OR nursing staff, the ICU staff, the other physicians, intensivists, as you mentioned, ENT, whatever, beyond the capacity of those other healthcare workers involved, you're not going to be successful., even if you are the best surgeon, you cannot do it alone. You cannot bring to a small town or to an inexperienced hospital to rise above, it's going to take a tremendous amount of work and recruitment to ever achieve that, is a very difficult task. So you have to keep that in mind when you're picking that job where you're going, that hospital and that practice can meet your expectations when you're going in.

- Thanks, Troy, I agree with you completely. So when you're picking an academic job, I think you've got to be comfortable with the team. You have to remember that you're a junior member and that it's going to be hard to be a generalist. And the only exception to this, is if you pick a job at such a, like a VA hospital or a county hospital, where you're the neurosurgical coverage, and you have to take care of all comers. You must define yourself in a respective area of interest and establish a sustainable research endeavor. And this is going to be an important theme if you choose an academic job, because really that's what defines your career as an academic specialist, you become a subspecialist, you develop a research interest, and then you need to have a sustainable endeavor to be able to be successful in an academic job. When looking for an academic job, I think the less rules defined in the contract, the better. The longer more detailed the written offer to a new faculty recruit, the more likely both sides will end up unhappy because you're working in a big complex system. These state hospital systems, for example, are very, they're very large and somewhat sclerotic, and the way they function. Often the contracts are boilerplate. You're not going to be able to put a lot of specific changes in your contract. Those are more relevant to a private practice opportunity where you can specify all the exact issues related to your employment, but oftentimes you really just have to accept it and go with the flow and go with the team if you're going to go with an academic job, especially in a large academic medical center. Troy, do you have any comments about that?

- I think that what you said is true when you go to most universities, they have boilerplate contracts that are very minimally negotiable. So, but I think that puts the person at risk, particularly if that job doesn't work out because they're potentially going to deal with non-competes and deal with just issues related into their departure whether it's not going to turn out well, certainly not from a financial point. Most of those contracts do not offer much protection to the neurosurgeon if it does not work out. So you should just be aware and be cautious of those things. Even though, unfortunately, in most academic centers, it's very difficult to get those terms changed.

- Right. So I just also wanted to bring to your attention what we call the Dilbert dilemma of academia. And I've seen this time and again, in academic practice in neurosurgery. And I really think it creates a Brownian motion of a lot of young people after their first few years years in practice. And the situation is as follows. You have a talented young surgeon and they want to be busy clinically, and they're eager to develop a practice. They go into a big group and they become successful and they really enjoy the academic work or the clinical work. And so they end up focusing on the practice and they don't focus on getting their research program up and running and they have less and less academic productivity. And then they say to themselves a few years into the practice, you know, I'm just so busy, all I'm doing is clinical work, and I could be in the community and make more money doing this, I should just be in practice. And I think this is a self fulfilling prophecy. I think it's a failure of mentorship in many cases from the leadership in the group. And it's very common. But I see it neurosurgeons particularly susceptible to this phenomenon. Troy?

- I think that is also the way the system sets you up to fail. The rewards, the incentives in an academic center are still more positive for clinical productivity than they are for academic productivity. And by incentives, I mean financial incentives, and that's generally the way people tend to respond. They look at the incentives and then they act accordingly. So, if the academic centers specifically rewarded academic productivity more, which obviously they cannot afford to do, but if they did, people would do more academic productivity, It's a problem, but it's not a surprising one that this principle exists.

- I think the fundamental problem that we have as neurosurgeons is that our clinical time reimburses so much better than our academic time.

- All right.

- So Joe Simone worked at the Huntsman Cancer Institute, here in Utah, and he subsequently went on to St. Jude's, but he wrote this lovely paper, which has about a dozen of these maxims that he learned during his career. And I just wanted to point out a few of them, the papers available on Medline. But remember that institutions don't love you back and that the institution has an infinite horizon to attain its goal, but an individual, especially a neurosurgeon, which has a really a 25 or 30 year career, has a relatively short productive period. So you have to really make hay when the sun shines. And personal attitude and team compatibility are grossly underrated in faculty recruiting. And I think these are often largely determinants of how successful a young faculty recruit is. Academic battles are recurring and continuous, no one can win them all.

- Can you advance that? Yeah, okay.

- I didn't hear

- The- or see the slide with all those maxims, now. I see it.

- Oh, I'm sorry, yeah. The fit in a new job is often not apparent for at least 18 months, and one should not consider an academic move for improvement anticipated opportunity of less than 50%. So you need to really think that the new job is a significant improvement or just stay put. Because every time you move, you'll lose ground, the wind comes out of your sails and you have to reestablish yourself in every place, reestablish your referral practice, reestablish your reputation among the patients and the physicians. Longevity in a position or institution is not a good measure of success, accomplishment or happiness. And in recruiting, first-class people recruit first-class people, and second-class people recruit third-class people, which I think is a good maxim.

- I agree.

- On partnership, there's no fixed formula. You're going to find many different ways on how practices determine a path to partnership. I think what you do need to know is how you're going to get there and have progress reports along the way, so that you know that you're on path to get there, because you don't want to find yourself three or four years into the job with no way of knowing whether you're going to make partnership. Troy, would you like to make comments about that?

- So this is one, this is one area where I think reading your contracts thoroughly, whether you join a private practice or an academic institution to understand exactly these issues, how are you going to be paid, define specifics of what they expect from you and how your promotion will be determined, specifically, if it's in an academic center, I mean, academic promotion. How will you become a partner? What exactly are the measurements that will qualify you for that? Because you don't want that to be a moving target. If it's a moving target, chances are you'll never get there. And once I will add, once you join, sign your contract, you're not going to get it changed later.

- Thanks, Troy. So, no individual or country ever sued himself or itself to greatness. And it's the whole, not the detail that matters. I think this is particularly important, the last one, when you go into an academic group, because in a big academic medical center practice, you're not going to be able to have that much opportunity to be able to change the environment that you're in, it's just simply impractical. And so you want to have a sense that you're joining a good team and then go with the flow and become a good productive member of that team. Understand the risk and reward compromise a partnership. You always give up some individual autonomy when you become a partner. Get an independent legal review of the contract. And remember that perpetual optimism is a force multiplier. Get to know your future partners. Interview past employees or partners. Why did they leave? Why did somebody not become a partner? What was the issue? Will you be able to achieve your personal goals within that group? Will you enjoy living in this environment or working with the individual group? And then small problems can become big issues. You can, they can fume and they can simmer over the years, deal with them upfront, be open, be honest. And remember that life is a compromise, that it's an imperfect world. This was something that Marty Weiss, who I trained with, told me some years ago, and that he always advised his residents that if you didn't know whether you wanted to go into academics or private practice, you should probably pursue an academic job until you get your board certification. And the reason for that is that it's always easier after a few years to go from an academic job to a private job, rather than the other way around, because your stock will be worth less if you spend a few years in private practice and haven't been productive academically. And then I think this is probably the most important one, all men and women want to succeed, but some wish to succeed so much that they're willing to work to achieve it. And I can't think of a more appropriate comment for both private practice and academics. And Troy, I'd appreciate your comments about some of these pearls and things that that I've shared here.

- Now there's a lot of good points there. This one is probably the best stated. You have to have realistic expectations when you go into any new job and the more work and effort you put into it, the more you're going to get out of it. It's not a situation. Some people start a new job and get the sense that they're being abused in that position or are overworked. But I think they should look at that as an opportunity. They're going to gain tremendous experience in doing that. And in time, depending on the structure and academics, it's more climbing a ladder and there's rites of passage with time and achievements. So I think you should look at these early years as an opportunity to set a groundwork for your future. And this statement says it all.

- So, Dr. Wilson, when I was a medical student, I rotated on the service at UCSF and Dr. Wilson was in his heyday at that time. And he quoted to me, I never met a referring doctor I didn't like, and I think that's a great comment. The three A's, availability, affability and ability, and maybe that's the most reasonable order, I don't know, I'd appreciate Troy's comments. But this was the old private practice maxim. But I think it's probably also relevant to academic practice nowadays, given that academic practices are under the gun for producing more RVUs than ever before. But, Troy, I'd appreciate your thoughts. You've had very successful practice in your career, and I appreciate your thoughts about this.

- So anybody who questions the importance of these things, all it needs to look at the way future reimbursement is being considered, looking heavily at patient satisfaction and most of residents, but certainly practicing neurosurgeons will realize that their affability and their availability is often more important than their ability. Even patients who have surgical complications, if they liked their surgeon, it's gonna go much better than if they don't. And obviously, if you're not available, your practice is not going to grow. If you're not affable, the patients aren't going to go back to their primary care doctor and say, what a great doctor he was, what a nice surgeon. That's how your practice is going to grow. People will accept complications if you have a good rapport and treated them well on a personal level.

- Right. The other thing that I think that the young people need to realize is that if you're a practicing physician in a community and you have a patient with a neurosurgical problem, you know, you want somebody that just takes that patient and takes care of that problem. You don't want to be sitting on that patient. You want somebody that graciously takes the patient, doesn't second guess you, doesn't get an argument about it, about transferring the patient. They really appreciate that. And I can't tell you the policy that we've always tried to develop and everywhere I've worked is that we just take the patient, take them off their hands, take care of the problem. Some of them may not be appropriate. Some of them may be relatively trivial to you, but it's a huge issue to the referring doctors. And it buys a lot of credibility down the line.

- That's an excellent point. If you establish a relationship as a center that will, or a surgeon that will accept patients, you're going to get some that maybe shouldn't be sent to you, or, but you're, if you do that, you're also going to get the good referrals too, because they're going to know this is somebody I can rely on, who's going to help me out when I need help. And that's the relationship you want to have with your referring doctors? You take the good with the bad.

- Absolutely. And remember that you're just beginning to learn how to be a neurosurgeon. And what I always quote to my residents and fellows, is that for microsurgery, you're just beginning to learn those skills. It's going to be another decade or two decades before you really start to master and we're learning throughout our career. So you're really not a fully formed neurosurgeon, you never will be. You're going to just hopefully get better all the time. And behind every successful neurosurgeon, there are a lot of unsuccessful years. Just remember that it takes time to build up referral practice, to build up trust and reputation. Any other comments, Troy, about some of the practice issues?

- I think you highlighted a lot of important points for residents looking at their options. And I would echo the comments we've made so far.

- Okay. So I just like to spend the last couple of minutes talking about some future predictions. And I think this is, these are just facts of life, we're witnessing these now, and that there's an active pressure out there to reevaluate the services that we do. But in general, I think it will result in decrease reimbursement from the third-party payers. There's a lot of pressure to reduce reimbursement to interventionalists like us, and to put more of the resources into primary care. And you've seen that with some of the, with some of the recent healthcare reform. The spine I believe, will become devalued more than the cranial work. And there'll be continued consolidation of complex cranial care to academic medical centers, just as we've seen with pediatric care over the last a decade or two. I think the majority of pediatric care is now delivered in pediatric teaching hospitals and consolidated there for volume outcome relationship reasons. And I see that with complex cranial cases as well. There's increasing size of group practice. I think Troy's group is a classic example of this, the decline of solo practitioners. There's power in numbers, as you heard him say. And I don't see, I think we're going to see Federal liability reform. We'll see some changes at a state level, such as Indiana, Utah's not bad with some caps on pain and suffering, but I don't see it happening Federally, at least in the next foreseeable future. Troy, would you like to make any comments?

- I think I'd agree with all of these predictions. The other thing we didn't specifically touch upon, which may be addressed in future presentations to that is, the impact of employment by hospitals. Neurosurgeons in the future will be employed by hospitals at a far, far greater rate than they are today. It's going to be 60, 70% of what are currently private practice neurosurgeons that aren't going to be hospital employed. And I think we're all seeing that all across the country.

- Troy, what do you think the consequences of that will be?

- Well, I think if you are a neurosurgeon near retirement, then that's a pretty good deal. Because when you look at it in most simple terms, the hospital pays for all your overhead. They pay your rent, they pay your malpractice. You just come to work, take care of patients and they pay you based on your work. You work out and negotiated, right? Whether that's based on RBU's or salary, whatever it is, but you just do the work, they pay you, and then you have no administrative issues to worry about. The problem is if you plan to practice for 30 years, you have to remember that you are an employee. And when you are an employee, the terms of your employment can change. Most of these agreements have at the most five years guaranteed in the compensation model. A lot of times I've seen contracts from hospitals where they'll say, oh, we guarantee you we'll pay you at this rate for five years. But then when you look at the section on termination, they can terminate the contract with 90 days notice. So you really have a 90 day contract that they can get out of it at any time, even though they promised it for five years. I think as an employee, you are at greater risk because as you said earlier, the hospitals don't love you back. When you join a group of independent neurosurgeons, you're working together for everyone's benefit. You're trying to make it better for everyone. In an employed situation, the hospital's trying to make it better for them. And they're going to try to keep you as long as they can, but they're not going to keep you at a loss. And if these reimbursements go down, they're not going to be able to keep paying you at that rate. And your opportunity to adjust to the market is much more limited when you're employed by a hospital. The other thing to be wary of when you're in an employed situation, is that there's frequently a non-compete. So many times if you don't like your job as employed by a hospital, your only alternative is to leave town, not to move to the hospital across town, but to leave the city completely. And that can be very problematic when you have a family. So I know we're going to do a session and there will be a future sessions for these presentations for the NNYS on this, specifically on hospital employment. But for the purpose of this, it is both of our predictions. I'll assume you agree that employment models with hospitals is a big future growth market. And I think neurosurgeons need to be wary of it. I'd be interested in your own comments on that.

- Yeah, Troy, I think you've covered a lot of my view on this as well. I think that people on the surface find a hospital employment attractive because it's simplifies life in so far as it, you're not running a practice, you're not dealing with decreasing reimbursement and fighting with the insurance companies to get paid, and individual contracts and running an office, et cetera. But the issue, the fundamental issue, is you're giving up a lot of independence and a lot of ability to make independent decisions and you are then beholden to your employer. And so I do see it as a continued trend. I think for the senior people, they're finding it fairly attractive right now, because it's a no hassle few years, and we don't know what's going to happen in the future with healthcare. But for the junior people, I share your concerns that they're giving up a lot of autonomy for a relatively short term security. And I just don't know whether that's wise in the long run. So I share your concerns. So the good news in my mind is that we're attracting outstanding people in neurosurgery. And I'm amazed every year at the quality of people that are applying for the residency programs, we're really getting the cream of the crop in neurosurgery, as we always have. The future of neuroscience is, has never been brighter. We have an aging population with an opportunity to treat diseases that we previously never thought possible. I mean, depression, Alzheimer's disease, they're all coming on the horizon. There's also this time, this magical time, when the technology now is catching up with the science and the ability to apply it in surgery, so that we can apply this fantastic technology such as DBS and convection enhanced delivery, et cetera, to previously untreated diseases. So, I can't think of a better time to be graduating as a neurosurgical resident. The growth is yet to be realized in malignant brain tumor, clinical treatment and head trauma. There's terrific opportunities in spine and endovascular functional surgery, as we mentioned, and also radiosurgery, and now ultrasound. So I think it's a terrific time to be a neurosurgeon and the world is your oyster. And Troy, do you have any concluding comments?

- So, Bill, like you, I think I'm the eternal optimist and for all the challenges we're facing in national healthcare scene and other challenges to the type of practice you have in neurosurgery, I think that demand for neurosurgical care is not going away. And in fact, it's growing, as you touched upon, there are more, the population is aging and there's more demand of that ever. The specific type of care that we provide will continue to change. You and I spent a lot of time in our training, learning to clip aneurysms. A future is endovascular. Yeah, there's still some aneurysms that need to be clipped, but fewer and fewer, it's just a reality of it. But that doesn't mean that aneurysms are going away. There will still be aneurysms to be treated, and they will always require neurosurgeons for their overall care. There's functional neurosurgery, is a huge growth market, and there will be things treated with DBS and other functional procedures that we don't even think about doing today. There's is clearly growth there. Obviously radiosurgery is still a growing market. Spine surgery is going to change, but back pain is not going away. There will be back and neck pain and there will be a demand for surgical treatment of those conditions, even though the specifics of the surgery may change. The demand for neurosurgery is strong today and will only be stronger in the future. I'm confident of that.

- Thanks, Troy. It's been an honor to do this with you.

- Well, thank you, I appreciate your comments, and hope everyone can learn something from our discussion today.

- Thank you.

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