Its plain and simple: your academic surgeons are wrong.
You can't blame them because all they see in academics are the OR cases which are relatively poorly reimbursed with low RVUs. In most academic medical centers around the US, image guided procedures are done by the radiologists and radiation oncologists. This is where the money is at.
I lose money when I go to the OR. It may not take me long to do a lumpectomy and I'll bill slightly more than $1000 but when you add in travel time to the hospital, MAFAT, dictation, talking to family, etc. its clear I make more money doing procedures in the office. Thus, considering a breast only practice without the skills to do your own image guided biopsies is tantamount to throwing money away.
For example, take the Mammosite mentioned above. This is an afterloading brachytherapy device to deliver partial breast irradiation. I am generally paid over $5,000 for what amounts to a 15 minute procedure, most of which is set up that can be done by my MA. The catheter costs me $2300 but you can easily see that there is nothing I can do in the OR for 15 minutes that makes me that much (ie, > $2500). Because I bill 2.5 times Medicare, I actually bill nearly $12K for the procedure and once actually got paid that much once by the insurance company (of course, once I only got $154 as well). It pays to watch those EOBs.
Even things that don't cost me much, like a 10 cc syringe and a 22 gauge needle for an FNA are profitable. A new patient consult, followed by a sonographic examination with US guided FNA will make me $1200 or so. Its a longer visit, so minute for minute, less profitable than the Mammosite, but still more than I can make in 40 - 60 minutes in the OR.
As far as having your own imaging on site, it is a must to have your own US. Most breast surgeons will tell you that its a "no brainer". A good office US will run you between $30 and $50K. From there, the equipment runs much much higher but the investment can be worth it, depending on the reimbursement. A stereotactic table runs around $200K but you need to factor in paying a tech into your calculations. My partner and I don't do enough of them weekly to make it worth the investment, so we do them at the hospital and bill the facility rates which comes out to be around $1200 for the procedure. Mammogram, MRI and PET-Mammo are feasible especially the latter two because the reimbursement for them is better. These modalities obviously require space, techs and a radiologist to read them, all of which need to be factored into the total cost.
Practice environments run the gamut from pure academic practice which is salary based to straight PP with surgeons only (my situation). You can work in a larger group which may employ radiologists or a breast center which has a large multidisciplinary staff. I have friends in all types of practice. There are less than 40 breast surgery fellows who graduate each year and the majority go into community practice (despite the belief of the SSO and ASBS faculty who tried to espouse the "fact" that breast surgeons went into academics, until I provided them with the data). Your goal, if choosing a community or PP environment, is to find a community where the radiologists support you doing image guided procedures, where the PCPs will refer to you (which is not really hard if you market yourself well) and the general surgeons do not feel stepped on. Many breast surgeons work in a large general surgery group and do all the breast. This can be advantageous as long as you don't have to take general surgery call. I consider myself lucky to find a large city which has very very few people only doing breast, where the norm is for the breast surgeons to do their own image guided biopsies and to have a good working relationship with the radiologists.
Do I make as much money as a Plastic surgeon? No. But if you believe salary surveys I make as much as a new general surgeon without the call, without the headaches and with better hours. Although everyone seems to think we only work 8 - 4, M-F, bear in mind that there is a lot of paperwork in PP that goes on after hours and that our colleagues don't see. Still, I work less than general surgeons. The patients certainly can be high maintenance and you need to have some skills in people management and communication, which many surgeons do not or do not desire to have. I will generally code a Level 5 consult for new patients, but if the return visits take a long time or involve complex medical decision making, I can code for prolonged time. All surgeons max out at Level 5 visits; unless you code for prolonged time, no one can upcode...there is no Level 6. I actually make more per visit than my general surgery colleagues because I have more components to bill and upcode for the extended time when necessary. You just have to know how coding works and know what you have to do. most general surgeons will code a Level 3, perhaps 4 at the most for new consults.
Most of my local OB-Gyns do not want anything to do with breast issues so I can see a patient who needs additional imaging or have a relatively non-complex problem and make a few hundred dollars for a short visit. Coordinating multidisciplinary care is part of the job but it takes me 5 seconds: my office staff calls the rad onc, heme-onc consultants and forwards my notes to them. I see the patient back to discuss what everyone said; obviously if its in the 90 days global I make nothing on that visit, but its generally a few minutes at most. I can bill for phone calls as well if they are lengthy.
All in all, I think its a pretty good life but you have to be part businessman/woman and understand how to maximize your income potential instead of assuming that everyone needs to go to the OR. I would also recommend doing a breast fellowship from a marketing standpoint as well as learning more about the other disciplines. It will be of immense help because many breast only positions, especially those in academics or breast centers, are advertising for a fellowship trained surgeon rather than a general surgeon.
