surgerytum

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I've been told by a few academic guys that you cannot do pure breast surgery in private practise and do well. If you choose this route, you're better off going academic. Obviously, I know of multiple examples of breast only private practises which seem to be still open for business. Running this by a few (non-breast) private guys, they agreed that it was possible to do well but that you had to have the right set up. Own the MRI machine, get in business with a bunch of breast radiologists, multiple office based procedures and you can make more from these things than from the surgeries you perform. Anyone care to comment on the opportunities available for someone to pursue a breast only private practise, what type of compensation to expect and the different types of practise set-ups available that are most advantageous to the surgeon. Thanks in advance.
 

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I've been told by a few academic guys that you cannot do pure breast surgery in private practise and do well. If you choose this route, you're better off going academic. Obviously, I know of multiple examples of breast only private practises which seem to be still open for business. Running this by a few (non-breast) private guys, they agreed that it was possible to do well but that you had to have the right set up. Own the MRI machine, get in business with a bunch of breast radiologists, multiple office based procedures and you can make more from these things than from the surgeries you perform. Anyone care to comment on the opportunities available for someone to pursue a breast only private practise, what type of compensation to expect and the different types of practise set-ups available that are most advantageous to the surgeon. Thanks in advance.
The academic guys are right there is no way that you can do just breast surgery in private practice http://forums.studentdoctor.net/member.php?u=4288
 

mik86

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if you see breasts all day at work, will you get used to them and no longer be attracted to them over time?
 
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surg

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Just like any other field, the real issue is what you mean by "doing well." There are plenty of breast focused private practitioners (heck about 45 breast fellows graduate a year, and most of them do not go into academic practice, they must be doing something to put food on the table). The largest breast surgery society has a large proportion of community based practitioners.

However, breast surgery is not a high RVU procedure as a general rule. (a lumpectomy/sentinel node is about 11-15 RVUs depending on if there is a wire or not, etc. Compare that to a liver lobectomy which is around 70 and maybe only takes 2-3x as long to do) Also, breast patients are notorious for needing more "hand-holding" which can eat into your clinic time, and you can really only max out at a level 5 with them. Top that off with the amount of multidisciplinary care you have to coordinate which is largely uncompensated time, and you start to think... hmmm... that's a lot of work for not as much money as some other surgical colleagues.

On the other hand, if you are well trained in ultrasound, image guided biopsies, offer mammosite, etc. Breast practice can be at least on par with other general surgery practices. The added benefit is, there are very few emergencies in breast, very few inpatient consults to interrupt your day, and few inpatients to round on. Imagine having no one to round on EVERY weekend. That can be done if you order your OR days correctly. Volume is definitely the name of the game though. You can't succeed as a breast only surgeon in private practice and do only a few cases a week. You need to be busy to cover the overhead.

Also, you have to really have a niche in the community. You are competing against general surgeons who will accept any referral from that primary care doc. The PCP has to think of you first for breast disease (while not being tempted to send you that fistula-in-ano as well). Offering as close to one stop shopping is probably the best way to do this. So while you don't have to own the MRI, you better find a radiologist that will service your patients efficiently and well. Likewise a good heme-onc experience helps as well.

Another alternative is to find a general surgery group full of people who don't like breast cases and who will basically let you join the group and take the breast stuff off their hands. It is surprisingly easy to find groups of surgeons who don't like breast patients and will give you all sorts of concessions (less call, etc.) to take care of those patients.

A multispecialty group practice also works well, as they are often willing to subsidize someone who is doing a good job, even if their RVU output is a little lower than the rest of the surgeons, it is still much higher than the PCPs in the group.

Winged Scapula probably has better insight since she just went through this job search for a breast focused job.
 

ESU_MD

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Also, you have to really have a niche in the community. .
The breast only surgeons I know do OK. I don't know how much money they make per se, but I am sure that they do well compared to the risks they have to take- the mammosite is a lucrative office procedure for instance.

They are NEVER in house pst 4pm, NEVER on the weekends, and I see them once or twice a year at night to drain a hematoma.

Breast surgery is a GREAT lifestyle.

I think the best setup is as part of a busy general surgery group who sends all the breast cases to one person.

I would imagine that being a female is an advantage. If I was a female, I would go see a female doctor who can relate to me, rather than some dude like me who just "doesn't get it" when it comes to breast disease
 

Winged Scapula

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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. :D

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.
 

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winged scapula I must say that is a great discussion regarding your current practice and provides a good bit of insight into what alot of residents don"t learn in residency. frankly I find the business aspect quite daunting. sadly that becomes such a large part of how well you do. even in academic medicine being held accountable for how much you bill is becoming more important.
 

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winged scapula I must say that is a great discussion regarding your current practice and provides a good bit of insight into what alot of residents don"t learn in residency. frankly I find the business aspect quite daunting. sadly that becomes such a large part of how well you do. even in academic medicine being held accountable for how much you bill is becoming more important.
On that note, WS (and anyone else who wants to chime in), how do you become comfortable with the business aspect of surgery? I'm definitely interested in breast surgery but have absolutely no business skills. Can you pick those up during residency somehow? Any suggestions?
 

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On that note, WS (and anyone else who wants to chime in), how do you become comfortable with the business aspect of surgery? I'm definitely interested in breast surgery but have absolutely no business skills. Can you pick those up during residency somehow? Any suggestions?
For most of us, I think it was a process learned on the job. Physicians are notoriously bad business people because we don't have the time or interest to spend learning about it.

During residency I picked up a vague understanding that the concept of coding and billing existed by looking at our check-out/billing sheets and some of the attendings would let me fill them out.

My fellowship PD was much more interested and knowledgeable about this aspect of practice and took the time to teach me. I took the ACS Coding and Billing Courses as well. The SSO, ASBS and some vendors generally offer coding courses or practice management classes. I just came back from a "Modern Breast Practice" conference in Dallas paid for by Ethicon and it was extremely helpful in understanding how to run a practice...the lecturers were some of the best known PP breast surgeons in the country and it was a small group (only 10 of us). These types of things are around, but are generally easier to access during fellowship when your schedule is more flexible than during residency.

I often recommend a book called "Finding the Right Job After Residency" to understand some basics about job contracts, employment models, etc. My partner is very understanding and helps me when I have questions, but I've obviously made a lot of mistakes and keep learning. My next project is to figure out if I can afford to buy into an ASC and whether its a good idea at this point in my career.

Its not hard to understand; it just takes time and interest. And when you realize that knowing more about it can make you more money, well the interest isn't hard to drum up. ;)

You HAVE to develop some business skills if you are running a breast center (because your cost centers will be monitored) or in PP. People will try and rip you off; so unless your mother is doing your books, you need to be aware of what you bill, how much it should pay and what you are getting, as well as what funds are coming in and out of the office.

Outside of PP, it behooves even academic surgeons to be aware of this and to use it to their potential. For example, my fellowship PD is very knowledgeable and as such, he bills more than any of the other surgeons in the Surg Onc department. So when he wants more time off or more money, he only has to show that he more than "earns his keep". Junior faculty also need to show that they are worth the salary they are being paid, so by learning ways to maximize income for your employer (the hospital) you keep your position more stable than the guy who is being paid more than he bills and collects. More and more employers will start to keep on surgeons on a pay for performance measure and the low producers may find themselves with a pay cut or no job at all.

You shouldn't be daunted as its easy to get started learning this stuff; keeping up with the constant changes (like recoding a majority of the breast CPTs last year, after I had memorized all the old ones) is hard.
 

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The real question for you is can you afford to NOT buy into an ASC. In the plastics world there are some people who say that they make more by owning a portion of their ASC than they do by actually doing surgery there. Just remember to split every different possible billing entity into a separate LLC.

I'm pretty sure that my financial priorities would be:

1. Make the lowest possible payment on student loans (cheapest debt you'll ever have).

2. If you can get a "good" home loan, buy a nice place now while the market is down and build some equity. Just make sure that you don't buy beyond your means.

3. Buy into an ASC. The rate of return (from what I've seen) is just about unbeatable as an investment.

4. Diversified investments.

There are several good business books for physicians out there. I've picked up a couple of them, just to make sure that I'm paying attention to the right things in residency.

I also look at the boss's billing sheets. I ask them why they use one code when I would have used another.
 

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Good advice Max, thank you.

My concern is that I'm not sure I want to go out on a limb and invest in all these things (ie, a new home, an ASC) when while I'm still a contracted employee and not a partner. While things are going swimmingly and I don't anticipate any problems, until my guarantee is up I don't feel comfortable spending all that money and not having a solid position here.
 

maxheadroom

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WS,

Good point. One of the best pieces of advice that a young attending ever gave me was, "Don't buy a house when you move to a new town/practice." Rent for the first year to figure out if you like the practice and you're going to want to stay (and if they'll keep you). That also makes it easier to figure out where you want to plunk down a big chunk of change on a house. Better to "waste" money on rent for a year than to end up trying to sell a house after only a year of occupancy.

I sometimes forget that lesson because I'm considering going back to my hometown. If I don't find a practice that I like, I'll start up on my own. Ugh. I can feel my ulcer starting up again already.
 

Winged Scapula

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WS,

Good point. One of the best pieces of advice that a young attending ever gave me was, "Don't buy a house when you move to a new town/practice." Rent for the first year to figure out if you like the practice and you're going to want to stay (and if they'll keep you). That also makes it easier to figure out where you want to plunk down a big chunk of change on a house. Better to "waste" money on rent for a year than to end up trying to sell a house after only a year of occupancy.

I sometimes forget that lesson because I'm considering going back to my hometown. If I don't find a practice that I like, I'll start up on my own. Ugh. I can feel my ulcer starting up again already.
And that is exactly what I'm doing.

I'm in a new community (ie, no family or other ties here) and a new practice so prefer to make sure I like it here, I like the practice and they like me.
 

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Max,

Not so fast on the ASC stock tip. There's a lot of trouble brewing on this issue from my understanding.

The goldmines that were freestanding ASC's are set to get crushed by facility fee readjustments (that were "back door'd" into federal legislation by the hospital trade lobby) and proposed "reinterpretations" of the Stark Law which could limit referral to an ASC that you own an equity position in (also being championed by hospitals).

ASC's are the next target after future specialty hospitals were knee capped.

I think you'll see more joint venture relationships with hospitals on ASC's which get's somehow exempted from the stark law issue
 
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Thanks for all the informative replies.

How about general surgical oncology fellowship training and then the decision to do breast only? Obviously it is possible- but are you as competitive for a breast only practise compared to someone who has done an SSO breast fellowship? My guess is NO but it does give you more options when you're done.
 

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Thanks for all the informative replies.

How about general surgical oncology fellowship training and then the decision to do breast only? Obviously it is possible- but are you as competitive for a breast only practise compared to someone who has done an SSO breast fellowship? My guess is NO but it does give you more options when you're done.
Its hard to say although there are Surg Onc grads who do only breast (ie, my fellowship PD, someone at Mayo, many other current PDs).

You could market yourself that way, but frankly since most Surg Onc programs only have you do a few weeks of breast (my PD only did 6 during his fellowship), it doesn't make a lot of sense to do Surg Onc if you only want to do breast because you will simply not have the experience of someone who has done a dedicated year.

Unless Surg Onc training changes, you would be most marketable at academic insitutions because you will not likely have learned how to do any of the image guided techniques (which is also currently true for the Breast fellowship programs at some of the big name places). As I noted above, without those skills, you are less marketable and it is less likely that a community or PP will be interested in you.
 

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I would say that it opens different door and closes other ones. As a group, I would say that surg onc fellowships do not provide as much breast as a dedicated breast fellowship (which is as it should be), however, there are exceptions. Some breast fellowships are pretty light on surgical rotations, others are light on imaging, etc. Similarly, some surg onc fellowships have a low volume of breast (either by time spent doing it or in dedicated rotations), others seem to have a high volume (Miami springs to mind, although that may have changed).

I would definitely agree though, that the average surg onc person does not get as much imaging experience or image guided biopsy experience in breast specific applications. However, it can be done with surg onc training alone. Breast ultrasound experience is becoming more common, and for all the time that you spend hitting liver lesions under ultrasound, once you learn how to find something on ultrasound in the breast (harder than it sounds), it isn't hard to learn to hit it with a needle.

Since the growth of breast fellowships, the number of surg onc trained people that want to do breast only has dropped dramatically through self-selection. However, a number of surg onc people still make breast a significant part of their practice and probably about 15% of surg onc fellows make breast the dominant part (50% or greater) of their practice I'd say based on the last few years of graduates.

As in breast fellowships, more surg onc graduates end up in the community than the powers that be really care to admit. They will see whatever comes through by and large, and I suspect that those without breast surgeons in their group end up owning a lot of the breast cases as well.

As to marketability, I think the surg onc side opens up the doors to groups that want someone that can do something more than breast and are looking for someone to take call. There is some worry out there that breast-only fellows will be dissatisfied taking call, etc. (which many of them will be) and thus won't share equally in the work. This can be solved with compensation differentials, but that can breed resentment as well. On the other hand, a well trained breast fellow can really market the idea that breast is the ONLY thing that they do, and well-marketed, this can be a powerful draw. Likewise, there is no worry that the breast fellow will show up at the group and suddenly decide that they don't want to focus on breast any more necessitating another recruitment if what they really needed was a breast person. (don't laugh, it happens not that infrequently with surg onc people)
 

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Excellent addition surg; thank you.

It is very true that one can encounter some animosity from general surgeons regarding the issue of call. There are ways around this and often, with the addition of the image guided procedures, we "earn our keep" and our colleages will give way on the call issues because of that and the fact that we will take the crap consults they aren't interested in (ie, breast pain, BRCA counseling, mass with normal imaging, etc.). As more and more hospitals go to acute care teams and general surgeons are not manning the ED, there appears to be less problem with this.

I'd write more but its after 4pm and I'm still at the hospital. Time to go home! ;)
 
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