How to evaluate a job

Setting

Practice models

Spine surgery roles fall into five practice settings. Each has different compensation, autonomy, and call structure.

Private practice — solo or single-specialty group. Highest income ceiling and most autonomy if you reach partnership. Income variability and overhead exposure in the early years.
Health system / employed — hospital or large multi-specialty group. Predictable base, benefits, lower administrative burden. Less control over case mix, schedule, and ancillary revenue.
Academic — university or affiliated tertiary center. Resident and fellow teaching, complex case referrals, research time. Compensation typically 20–35% below community equivalents.
VA / military — federal employment. Defined hours, pension, loan repayment, GS pay scale plus market pay. Limited surgical volume in some sites.
Locum tenens — contract coverage, daily or weekly rates. Useful as a transition or supplement; not typically a long-term career stage by itself.

Compensation

Compensation structures

Most spine offers reference MGMA or Sullivan-Cotter percentile data. Common structures:

Base + wRVU production — most common in employed roles. Ask the conversion factor, the wRVU floor, and the threshold above which production kicks in.
Income guarantee — common in early private-practice years. Usually two years, sometimes forgiven against future collections. Read the recapture clause.
Straight collections — pure eat-what-you-treat. Common at partnership in private practice. Ask the historical collection rate by payer mix.
Overhead — how it is calculated (percentage of collections, flat allocation, or hybrid), what is included (rent, staff salaries, billing, supplies, malpractice), and how new hires or equipment change your share.
Signing and retention — separate from base. Confirm forgiveness schedule and tail.
Ancillaries and ownership — surgery center, imaging, PT, real estate. Confirm whether and when you can buy into each.

Partnership

Partnership track

Private-practice partnership terms vary widely. The items below determine whether a partnership is meaningful or nominal.

Buy-in price and method — fixed dollar amount, a multiple of EBITDA, or a haircut against future collections. Each has very different tax and cash-flow consequences.
What you are buying — equal share of the practice corp only, or also the surgery center, imaging, building, and any management entity? Ask for the org chart.
Vote and governance — equal vote at partnership or weighted by seniority. Veto rights on hiring, expansion, payer contracts.
Buy-out terms — what happens on exit, disability, or death.
Track record — how many of the last five associates made partner on the original timeline.

Call and case mix

Call structure and case mix shape day-to-day practice. Items to clarify before signing:

Trauma call frequency — 1-in-how-many, including weekends. Negotiate stipend separately from base.
Backup vs. primary — primary spine call is materially different from being secondary to general orthopedics.
Elective mix — degenerative cervical and lumbar, deformity, tumor, revision. Confirm which cases you are expected to handle from day one.
OR access — how block time is allocated, how easy it is to add on cases, first-call vs. open block, robot or navigation availability.

Referrals and triage

Where the patients come from and who decides which patients reach the surgeon shapes both case volume and case mix. Items to clarify:

External referral sources — physiatry, primary care, neurosurgery overlap, pain management. Ask what share each contributes and which sources are growing or declining.
Non-operative back pain — who in the practice sees patients who do not need surgery. An in-practice physiatrist, PA, or NP, or are non-op patients referred back to the PCP.
Urgent care triage — if the practice or affiliated hospital runs an urgent care or walk-in spine clinic, how it decides which patients are routed to the surgeon vs. conservative care.
Pre-clinic screening — who reviews imaging and history before a new patient is placed on the surgeon's schedule, and whether non-surgical candidates are filtered out upstream.

Team and operations

Day-to-day spine practice depends on the support team and the operational governance around it. Items to clarify:

PA or NP support — when an advanced practice provider is added for you, who pays their overhead, whether you receive a share of their collections, and what patient volume typically triggers the addition.
Medical assistant — who supervises your MA, whether you can choose them, whether they stay assigned to your panel or rotate.
Clinic scheduler — who controls your clinic template, who can override it, how new-patient slots are protected, how follow-up slots are sized.
Surgical scheduler — who books your OR cases, how OR time is requested on your behalf, how add-ons are prioritized.
Clinic template ownership — who can change your template (you, the practice administrator, the clinic manager) and on what timeline.
Performance reporting — who tracks your wRVU production, collections, and panel growth; how often you receive a report; against what benchmark.

Local market

The geographic, market, and community context around the practice. Items to clarify:

Geography — distance to the nearest major airport, cost of living, schools, climate.
Surgeon saturation — number of spine surgeons (orthopedic and neurosurgical) practicing in the area, and the trend over the last five years.
Surgeon community dynamics — whether local spine surgeons collaborate or are fractured. Active feuds or lawsuits between surgeons surface in referrals and OR scheduling.
Community attitude toward spine surgery — whether patients in the area tend to seek surgery proactively or are skeptical of it. Affects clinic-to-OR conversion.
Tort climate — state malpractice environment. Damage caps, statute of limitations, jury history. Affects insurance premiums and case acceptance behavior.
Patient population — blue collar vs. white collar mix, demanding vs. trusting, workers' comp share, payer mix.

Hospital and OR

Hospital and OR culture

Items to clarify about the hospital team and culture you would operate within:

Preoperative medical support — availability of primary care and cardiology willing to clear complex preop patients, and whether the practice has standing relationships with them.
Anesthesia — whether the anesthesia group is reliable for spine cases (positioning, blood-loss management, neuromonitoring coordination), or whether you need to micromanage.
Equipment — intraoperative imaging (O-arm or C-arm), navigation and robotics platforms (e.g. StealthStation, Mazor, ExcelsiusGPS, ROSA), neuromonitoring capability (SSEP, MEP, EMG), surgical microscope, specialty tables (Jackson, Allen), endoscopic and MIS instrumentation, and which implant vendors are on contract.
OR staff and surgeon preferences — whether scrub techs and circulators know your preference cards, or whether each case starts from a blank slate.
Floor nursing — postoperative competence with spine patients, brace and drain management, and how reliably concerns are escalated.

Lifestyle

What the job looks like outside the OR. Items to clarify:

Locations — number of clinic and hospital sites, driving time between them, and the coverage expected at each.
Team call and cross-coverage — how call rotates, whether partners round on each other's patients on weekends and during vacations, and how handoffs are documented.
Postoperative responsibility — who manages a postoperative complication such as a wound infection or hardware issue: the primary surgeon, the surgeon on call, or both.
Meetings — frequency of obligatory weekday afternoon meetings, whether they cut into clinic or OR time, and how often weekend meetings or retreats are expected.
Social calendar — how often partner dinners occur, whether spouses are typically invited, and whether there are family gatherings among the partners.
Partner fit — whether you would enjoy being around the partners as people, including political, professional, and team dynamics.

Due diligence

Questions to ask

Send these questions in writing before signing. Verbal answers do not survive personnel changes.

Show me the last three years of partner compensation by quartile, and the wRVU production behind it.
What is the historical collection rate by payer, and which payer contracts are renegotiating in the next 18 months?
Who owns the surgery center, the imaging, the building, and the management company? What is the buy-in for each separately?
What is the non-compete radius and duration? Is it enforced? Show me the last two associates who left.
What is the call schedule today, and what changes when I join — does my arrival lighten the load or backfill a departure?
Who decides hiring, partner promotion, payer contracting, and capital projects? Show me the governance documents.

Negotiation

Negotiable terms

Base salary is usually the least negotiable line in a spine offer. The structural terms below are typically more negotiable and have larger long-term effect.

Buy-in source — negotiate practice financing of buy-in against future collections, not an outside loan with after-tax dollars.
Ancillary equity vesting — push for proportional ancillary equity at partnership, not a separate later buy-in.
Call stipend — separate, taxable, and uncapped above a threshold. Easier to negotiate than base.
Block time guarantee — minimum OR days per week in writing.
Non-compete — narrow the radius before signing. After signing the leverage is gone.
Tail coverage — confirm who pays the malpractice tail on departure. Six-figure exposure is common.