Recently, I had a fellow in my office at the tail end of his fellowship. He had made the decision to go off into private practice, on his own, far from his family friends. As he prepared for a new life in a new city and a new existence, he paid me a visit seeking any pearls of wisdom I could provide. Many can remember this time period with multiple stressors, board exams, a new job, strange unfamiliar responsibilities, possibly a young family or on the precipice of starting one… and all the decisions made in this short span of time seem to have vast importance.

I get visceral pangs of excitement, nausea and anxiety all brewing together when I think back on that period. But mostly I reminisce positively, even though I may have not realized it, the moment was fertile with endless potential. Our first true opportunity, a tabula rasa to create whatever desired. Nothing is impossible and all is at stake. And I certainly had my fair share of mistakes… none of which I can say I truly regret but there were many potholes I probably could have avoided. However, I neglected to tell him how to steer clear … instead of giving him the practicalities, I fell in line and reflexively spat out the standard idealist mantras that we already all know and that can be found draped all over the self-help section of any local bookstore.

“Love what you do,” “always do the right thing,” “treat patients not diseases,” “don't cheat steal or lie,” “marry for love” and “always call your mother.”

However, I missed out giving him the tips that probably really matter the most. The somewhat salty, certainly cynical, nitty gritty pearls to survive and thrive in practice. But after he left I gave it more thought…I came up with a better list … although not inclusive as I didn’t want to overwhelm, so I narrowed it down to 10.

1. Never fully trust your professional advisors. (Accountants, Lawyers, Money Mangers, CFO’s, Business manager, etc.)

This goes under the philosophy that nobody will ever care about your finances as much as you do. While we all likely hire top notch professionals, most of us who have been in practice long enough recognize that there are times, perhaps rare but nonetheless, when our accountant or lawyer may overlook a fact that is critical to our existence or situation. Keep your eyes on your books, and I recommend having a third set of eyes look them over. Because if you are in practice long enough eventually someone will try to steal from you. And red lights should go off if someone you recently met regardless of their profession, tries to convince you to partake in a “great” deal that is sure to deliver fantastic returns.

2. Hire the best talent available regardless of the position needed.

My experience has been that strong talent always finds a meaningful purpose. And often times it may take me in a direction different than what I expected but regardless that person was passionate and productive and my practice always was the better for it. The corollary though is that truly talented people will likely eventually want to grow beyond your realm. And that is ok too. Their next stop may also prove valuable to you.

3. “I told you so” gets you nowhere.

It may make you feel better in the short term but it has no redeeming value. This goes under the philosophy of not letting your ego get in the way of good medical judgment or a prudent business decision. Having a healthy ego is probably a necessary character trait to being a surgeon but learning to dampen it will bode well for both professional and personal growth. Success resides in an ability to control your appetite and emotions. Few will fancy an angry outburst as anger always leads to destruction. Learn to compromise, the greatest leaders and most productive pioneers all commanded this strength.

4. An absent leader is an oxymoron

A captain needs to be at the helm directing the ship and forging the route. He/she must lead by example as his/her actions and behaviors are being watched, as are yours. Beware complacency for it leads to death, uncertainty heeds discontent. Consistency though breeds comfort.

5. Your enemy today maybe your best friend tomorrow and vice versa.

Measure your words and actions carefully as you one day may be surprised by who will be the one to back you in a crisis. We all take different routes for different reasons. Taking pride and appreciating those differences quells adversary, tempers competition and often leads to symbiotic relationships.

6. You have to make a meaningful difference to be relevant

Don't confuse being busy with being productive or making a difference. Today it is much easier to be flashy and to spark interest but to make a meaningful and lasting impact you will need to find a creative insight that has yet to be expounded. And once you do don’t be surprised if others think you are pushing the envelope, that maybe good but always know where boundaries lie.

7. The best resources from which to create something special is nothing 

This goes under the philosophy of don’t spend what you don’t have. It is easy to want the latest and greatest new toy, but often it doesn’t turn out to be as great as anticipated and when you start with nothing you get awfully creative often finding a new and better way to get to the same place as everyone else. If, however, a purchase is a necessary then always get three quotes before deciding.

8. Those who boast they will send you patients often don't.

Beware the bearer of gifts and fear the flatterers. They quite often expect something of greater value in return.

9. Be aggressive in thought but cautious in action and speech

Think big but plan actions one or two steps ahead. Reflexive behavior and rash decisions often lead to a quick demise. Anything good never happens fast. Allow things to develop, including the latest trends. Don't be in such a hurry to be the first to adopt a new technology or procedure. Realize that those in the front of the charge usually take the most arrows.

10. Listen, Listen and then Listen some more

This could single handily be the most important tip I can provide, whether in consultation with a patient, in a review with an employee or in a tiff at home you are more likely to make the correct diagnosis and choose the best course of action if you master the skill of listening.

While not a complete list, it is my top ten practical pearls of practice, what would be yours?