This might've been asked before but is it true in private practice, you usually see spine cases more frequently, but in academics, you can work more on the brain? I'm curious regarding the better practice environment for someone interested in vascular (or endovascular) cases and/or cancer cases. I was thinking academics from what i'm seeing but not sure.
Thanks again for the help and advice
@neusu @mmmcdowe
I have addressed this in other places, both in this thread, and in others. As an attending, the number, and variety of, cases you do, and amount of call you take, is at your discretion. In a pure sense, this is absolutely true, no one can really make you do something. In reality, it tends to get a bit muddy.
To answer your question, yes, there are successful private practice vascular/endovascular neurosurgeons. There are successful endovascular neurologists/neuorradiologists. There are successful open vascular neurosurgeons. Expecting that you will come out of training, and be handed the keys to the kingdom, and be able to do only the best cases, while not doing any cases you dislike, and maintain an income you expect, keep the volume required to continue to do such complex cases is foolish. Most neurosurgeons that are interested in vascular, any more, have to do both open and endovascular, to be competitive in a job market. Academic centers tend to allow for more flexibility to pursue academic interests, likewise, be larger centers, with specialists, which means you would be funneled the cases within your specialty.
That being said, reality is this such that no matter where you train, when you finish, you're back at the bottom of the totem pole. Everyone else in the academic department has seniority, or everyone else in the community private practice has already established referral patterns. You have to put in your time taking trauma/stroke call, doing wound washouts, and clinic to establish your reputation. Likewise, no one wants to talk about it, but income matters. If you're in private practice, eating what you kill, those student loans don't pay themselves off, and by the time you finish college/med school/residency/fellowship (+/- PhD/military to pay for it if you want to get the financial obligations out of the way), you're in your 30s-40s and want a family. Forgoing thousands of dollars a year to be an elitist/purist is lacking common sense. Likewise, in a group or academic center, where your productivity is measured by the RVU, again, you're unlikely to meet your numbers being selective early on, and have your salary significantly cut. Be careful, look at the contract, I've had friends burned by eye-popping signing bonuses and first year/two year salaries, only to find out when they didn't meet their numbers, it was structured as a loan, so they have to pay it back. Further, being known as the surgeon who tut tuts and only wants the good stuff is not good for your reputation, leading the referral pattern to not form. This leaves call as your primary source of patients with pathology needing treatment. I'll tell you, any of my friends/colleagues who are chairmen/directors of vascular and can afford to not take call, don't. The reason they can afford it is they get enough elective referrals that they can forgo call. This helps them in their lifestyle and sanity, and the more junior attendings build their reputation.
Finally, spine pathology is far more prevalent than brain pathology. The incidence of brain tumor in the general population is ~3%. Aneurysm ~2%. Back pain 80% of adults experience it at some point throughout their life. Are all of these operative? No. Anterior circulation aneurysm < 7 mm, for instance rarely rupture, so the 2 mm AComm in your clinic likely will be followed. Same thing with the L4/5 disc herniation. That being said, looking at raw numbers, there are a lot more patients with back pain, that progress through the system of medical/conservative management and require surgical treatment (decompression/stablization etc). Thus, across the board, the average neurosurgeon does do spine surgery, and in private practice, may do more spine than cranial, simply by population needs.
