I have looked for this a bit online, and haven't quite found exactly what I want to know. I am very interested in plastics (particularly reconstructive). What is the lifestyle like for an integrated program? How does the lifestyle change over the course of the program? I want to have children and it's looking like residency will be the right time. How compatible is plastics residency with family life? What about a reconstructive private practice?
Plastics Residency Lifestyle?
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it says you are pre-medical. Always good to think about the future but trust me, you are far from needing an answer to this question. so many pre-meds think they want to do plastic surgery, neurosurgery, etc., and then change their mind. It's not worth worrying yourself about such specifics when you aren't even in medical school yet. medical school is long, and you will have plenty of time to figure these things out for yourself.
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I think that the best summary to the question about residency is, "residency blows." true story. BUT, if you love what you do, it's worth it. There are days of residency that I hate it, and have been in the hospital for what seems like days, and I don't want to spend another minute there. It affects your relationships, your health, and everything else around you. Luckily those days are balanced by others where I can't imagine doing ANYTHING else with my life, and wonder why I would ever even want to leave the hospital or operating room. I promise you that if you go into any specialty for the wrong reasons you won't stick with it. It's important to have a good support structure around you to be there through the thick and thin. Some programs are way easier than others, and this is particularly true in plastic surgery. You don't have the same volume or responsibilities at every hospital. If you want to start a family, there are many family-friendly programs out there. It also helps to have a supportive spouse who can share the home workload with you or who can help you afford child care. All residencies, however, will be very difficult and will challenge you in every way, especially surgery. Plastic surgery is most certainly not a "cush" residency. It's at least 80 hours a week at most top places, you round early, stay late, and operate all night if you have to, just like every other surgical specialty. If I were married and ready to have children, and if it was the right time for the two of us to start a family, I would go for it and just make it work! We are surgeons, that's what we do.
Well put. Many good points made in this post.
1. No surgical specialty is "easy." Period.
2. When it's bad it's real bad. I don't know what PRS is like yet, but we see them in the trauma pit sewing up face lacs at 2 AM on a very regular basis. How often will depend on the specific program you match in to. Don't forget about hand call either...
3. One of my biggest frustrations with residency has been my inability to work-out as much as I want and having to eat the s*** food in the cafeteria when on call. Granted, I was an athlete my entire life so it's always been something I enjoy. I'm not sure if others would be as irritated by working out "only" twice a week.
4. A chief resident once told me the best career decision a person can make is their spouse. I've found that to be incredibly true. The support at home, both emotional and financial, is priceless and keeps me from both punching a hole through a wall (not a good look) or letting the interest run wild on my student loans.
5. If you wait until you've got enough money and time to easily raise kids, you'll be 45. Just go for it and figure it out as you go. Plenty of residents, even in gen surg, have kids. Is it easy? Prob not.
6. A solely reconstructive private practice is pretty hard to pull off. The cases are long and the reimbursements have dropped quite a bit. There are many threads with PRS attending level input on SDN addressing that topic .
Last, there are about a million hurdles you have to get over between now(pre-med) and the residency match as a MS4. Work as hard as you can at everything you do regardless of whether or not you think it's relevant to your future. That was my mistake when I was younger. That's prob the best strategy at your stage.
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My plastics residency was 100,000x easier then my general surgery in terms of intensity, hours, patient acuity, and associated bullsht. I really enjoyed both experiences, but I don't think I could physically and mentally do surgery training again. My plastics OTOH was a lot of reading and operating with minimal patient care. It was challenging mentally, but it wasn't anything like the physical grind of doing several months in a row of Q2 in house trauma call and spending 40 of every 48 hours in the hospital which was the norm back then.
My practice is actually good QOL, but the business side of it is just a grind. The margins on insurance and cosmetic cases is increasingly stressed by reimbursement cuts and competition for cosmetic procedures from multiple disciplines (many non-surgeons, some not even physicians at all). The ability to do a predominately reconstructive private practice is really going to be challenging going forward as we ain't seen nothing yet in terms of reimbursements getting haircuts under the ACA and the types of business practices it's going to create. There just aren't any plastic surgeries that are high volume enough to maintain salaries, and that reality is going to be reflected in salary negotiations with hospitals/ACO's where these practices are going to be clustering. In an "eat what you kill" salary market, we're going to see salaries cut 30-40% for reconstructive plastic surgeons I would imagine.
My practice is actually good QOL, but the business side of it is just a grind. The margins on insurance and cosmetic cases is increasingly stressed by reimbursement cuts and competition for cosmetic procedures from multiple disciplines (many non-surgeons, some not even physicians at all). The ability to do a predominately reconstructive private practice is really going to be challenging going forward as we ain't seen nothing yet in terms of reimbursements getting haircuts under the ACA and the types of business practices it's going to create. There just aren't any plastic surgeries that are high volume enough to maintain salaries, and that reality is going to be reflected in salary negotiations with hospitals/ACO's where these practices are going to be clustering. In an "eat what you kill" salary market, we're going to see salaries cut 30-40% for reconstructive plastic surgeons I would imagine.
Droliver,
I'm currently a GS resident tentatively planning to pursue and independent PRS residency in 2016. Right now I'm doing a year in the lab, getting to see some pretty awesome recon cases at a high volume cancer center. Everyone seems happy with their career choice and, overall, it's been a great experience. So, interest in PRS is not what troubles me when considering it as a career. It’s cool, I enjoy it quite a bit.
My question is, for someone who will be in practice for the next three decades, will PRS be a sustainable business model?
You've mentioned declining reimbursements for recon and intensifying competition for cosmetics as a couple of headaches you're dealing with. I don't foresee either of those things getting any better. There's a new OB in my hometown that’s doing breast augs and doesn't even call himself an OB/GYN, he's advertising himself as a "cosmetic surgeon."
Whenever the topic of money comes up, people always give some trite and cliché "money doesn't matter do what you love" nonsense response that probably worked for people 20 years ago when debt was lower, reimbursements were higher and the fed wasn’t exploiting medical students by charging ridiculous interest rates on their loans all while threatening to cut GME funding. The reality for my generation is unless you come from money, ignoring the massive amount of debt hanging over your head or pretending like you’re “above money” is not admirable; it’s stupid and irresponsible.
The concern regarding debt and salaries amongst residents is ubiquitous and I've been told by multiple people (who may or may not actually know what they’re talking about) pursuing PRS is one of the worst financial decision a GS resident can make considering our graduates have been getting offers of 300+ with no fellowship in places like Houston. The offers to go down to the valley are insane...
So really, my follow-up question is would you pursue PRS again if you were still a pgy4 GS resident? From your post, it seems like you’re describing a struggling business model in an era of a failing healthcare system that seems to think the solution to everyone’s problems is to cut physician reimbursement. That sounds like a pretty big gamble to me…
I'm a medical student, but I don't know how to change my account. There's nothing wrong with wanting to know.
Which programs are known for being family-friendly?
Knowing which programs have a rep for being "fam friendly" is certainly helpful in terms of planning away rotations. It's good you're being proactive about your interest and have your priorities straight.
One of the reasons you're prob not getting a ton of "x program is definitely family friendly" type responses is because that's a pretty difficult question to get a straightforward black and white answer. The less than PC answer is, some people are whiners/crybabies and consider working more than 50-60 hrs to be "hardcore" while others would consider 60-70 hrs a week to be a cakewalk. It's doable in any residency though. Even the gen surg ladies are popping out babies, performing well clinically and seem happy overall. One of my friends is an integrated CT resident and also super mom from what I hear.
Taking a dedicated "research year" to have a baby would probably be the easiest route to go. That's pretty common.
Overall though, unless you're planning on only applying to "family friendly" programs, which would definitely not be the smartest decision given how competitive integrated plastic is, you should shot gun apply all over the country, go on all your interviews and sort out which programs seem family friendly.
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Dr. Oliver,
I want to pick your brains... Have you come across any instances of private/group practices that were predominantly reconstructive and cash payment?
I would think it's possible with things like breast recon... because of the following reasons:
1) Fairly high volume set of procedures: 12% of women? Though I know that not all consider recon, especially older women.
2) Could be reasonably done in outpatient/surgi-center settings (tissue expanders and some autologous?), obviating the reliance on hospitals?
3) Relatively few super emergent complications? Except hematoma and maybe rupture? Many complications that can be managed in an outpatient setting by midlevel providers?
4) Significant cosmetic considerations that might leave room for niche expertise and appeal to surgeon shopping?
The reason I ask is because I remember meeting a surgeon out in California who was very skilled with breast recons (I met/saw many of his patients in various stages of recon and thought his work was just amazing....). Anyway, I heard rumors that he was essentially taking cash only or very select insurance plans and yet being ridiculously overbooked with people willing to pay for his work. Do you believe this is plausible?
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"I want to pick your brains... Have you come across any instances of private/group practices that were predominantly reconstructive and cash payment?"
That kind of model really has no future. In recent years there were a small handful of guys that set up practices doing DIEP flaps out of network (OON) at tremendously inflated prices (think $20-40K fees). That's really the only cash based recon. practices that popped up. What's happened over time is that
1) there's a lot more surgeons coming out of training doing free flaps (higher chance an in network insurance provider exists)
2) OON benefits are disappearing from most people's insurance or becoming prohibitively expensive
3) the overall economy is bad and reducing many people's free cash
These things have all come together to price OON fee for service out of the reach of most people. The ACA is also set up to limit provider networks and increase out of pocket expenses for patients. Outside the very wealthiest patients, there's really not a whole lot of people willing to spend that money out of pocket for this as they're already often getting hit with 20-30% premium increases and higher deductibles. We do a handful of self-pay breast reductions and such, but that's a super limited slice of patients presenting for a procedure covered by insurance. Surgeons thinking their current niches doing some of these OON practices will continue just haven't been paying attention to what's going on around them. Also in the future ACO setting, there will be tremendous cost pressure on choices for medical care. Exotic microsurgical breast reconstruction procedures like a DIEP flap will almost certainly be challenged as the expense will be coming out of the profit margin of the bundled payment to an ACO (who most often will be your employer in intergrated hospital systems going forward)
Unless you're in a situation where your salary is going to be subsidized by an institution as a critical access service (ie. a level 1 trauma center, hand trauma coverage, etc...) a reconstructive surgeon is likely going to see a 30-40% pay cut in a straight forward production-based salary incentive system.
That kind of model really has no future. In recent years there were a small handful of guys that set up practices doing DIEP flaps out of network (OON) at tremendously inflated prices (think $20-40K fees). That's really the only cash based recon. practices that popped up. What's happened over time is that
1) there's a lot more surgeons coming out of training doing free flaps (higher chance an in network insurance provider exists)
2) OON benefits are disappearing from most people's insurance or becoming prohibitively expensive
3) the overall economy is bad and reducing many people's free cash
These things have all come together to price OON fee for service out of the reach of most people. The ACA is also set up to limit provider networks and increase out of pocket expenses for patients. Outside the very wealthiest patients, there's really not a whole lot of people willing to spend that money out of pocket for this as they're already often getting hit with 20-30% premium increases and higher deductibles. We do a handful of self-pay breast reductions and such, but that's a super limited slice of patients presenting for a procedure covered by insurance. Surgeons thinking their current niches doing some of these OON practices will continue just haven't been paying attention to what's going on around them. Also in the future ACO setting, there will be tremendous cost pressure on choices for medical care. Exotic microsurgical breast reconstruction procedures like a DIEP flap will almost certainly be challenged as the expense will be coming out of the profit margin of the bundled payment to an ACO (who most often will be your employer in intergrated hospital systems going forward)
Unless you're in a situation where your salary is going to be subsidized by an institution as a critical access service (ie. a level 1 trauma center, hand trauma coverage, etc...) a reconstructive surgeon is likely going to see a 30-40% pay cut in a straight forward production-based salary incentive system.
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I love what I do, but you do feel like you getting squeezed on all sides in terms of overhead creep and declining insurance rates.
It will be sustainable, just much less rewarding financially. The same discussions were had about 25 years ago where the 1st big cut in "usual & customary" fees hit medicine. I don't know how a plastic surgeon outside a large metro area will stay in practice as you won't be able to stay in business doing traditional reconstructive surgery and little cosmetic work. The math just doesn't work.
I don't know that the traditional model (5+3) makes a lot of financial sense anymore with the length of training, uncertainty of the field, and large debt most people carry. 2-3 extra years in training at low salary represent a lot of opportunity cost
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Thanks for those insightful comments. I thank my lucky stars for an integrated position.
Quite the dilemma. I find that most PRS say they truly enjoy their work (in contrast to many GS I ask) which is encouraging, but certainly for someone who has finished a residency and has the potential to make grown up money extending training 2-3 years is a big deal. I'm also not sure I entirely buy in to the "you have to do what you love" thing.
Thanks for the advice. I appreciate you taking the time to respond. Attending level input is always valuable.
Not to discount the excellent points noted here, but make sure to solicit some other attending level opinions. There truly is a broad spectrum of opinions about the future (and even current!). I know a chief from a top program who can't find a job he likes as well as a chief from the same program starting out at base 375k with large RVU productivity bonuses because the hospital really wants them. Personally, I think the PRS outlook averages out to the same as every other surgical specialty - the cons of ACOs cited here will ding everyone else too. When otitis media becomes a bundled payment with incentives to not put ear tubes in ENT will get it, etc.
From a financial standpoint much probably does come down to aesthetic. If you're not interested/don't think you can generate a practice that has any of that then you're not going to make that much more money than GS (which shouldn't be surprising). But the vast majority of plastic surgeons manage to have a significant component of cosmo. Plus for a lot of us it came down to what you do at work; everything becomes a bit routine after a while but I just didn't like general surgery operations and I still like plastic ones.
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While these are all great points, I think we have gotten off topic. The original question related to lifestyle during integrated residency programs and how the lifestyle changes throughout the program.
