cncrsrgry

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I will be finishing g-surg residency at the end of Decemeber (had to do 6 extra months because I was in a major car accident). I have done 2 years of research in the lab with several publications. I had always intended on doing a surgical oncology fellowship. I enjoy whipples and livers and gastrectomies and colons but my personal close call with death has made me realize that there is more to life than spending my weekends and nights in the hopsital taking care of these patients. I have found that I enjoy breast surgery too. I enjoy the patient population and the multi-disciplinary aspect. Obviously, the lifestyle component is a big bonus too. I do not intend to do academics. I have a few friends that are doing breast and surg onc and it seems as if the breast fellows are getting incredible offers- as good or better than the surg onc guys.

I always thought I would have to take a major paycut by doing breast surgery versus general surgical oncology. If this is not the case, I would go down the breast route. I have ~ 250K in debt and three kids. My wife is a kindergarden teacher- so money is a big consideration.

perhaps winged scapula would have the most insight.....
thanks to all in advance
 

droliver

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Kimberli may have some other insight, but the lifestyle issues with "breast surgery" as a practice are colliding with the department of surgery requirments for general surgery call at at least 3 hospitals in my city alone. In many environments, you're going to have trouble limiting yourself to just breast.
 

ESU_MD

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Breast only practice can have a nice lifestyle, (limited call/weekend responsibility) I heard of some breast fellowship grads getting really nice starting offers.

I'm not sure, but I bet even being a fellowship trained breast surgeon, your options will be more limited as a male vs female though. A rare case of reverse gender discrimination in the surgical field
 

BlondeDocteur

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Breast surgeons can clean up financially. The cases are by and large short, meaning you can do 6-8 a day. I was surprised to find at Memorial that the breast surgeons are among the most well-compensated because of that.
 

surg

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If you enjoy breast surgery and are willing to limit your practice, do it. You certainly will not be better trained to do breast in a surg onc fellowship than a breast fellowship so why suffer through a longer fellowship (2-3 years v. 1) and do more cases of something that you don't intend to continue in your practice?

As a surg onc trained person who does a lot of breast, i think it's true that there are fewer RVU's per operative case in breast than in the big surg onc cases, but as someone else noted, you can make up some of that in volume. If you find a program that can get you well trained in U/S and image guided biopsy, you can make up the rest in clinic without difficult if you are reasonably busy.

Lifestyle wise, even if you have to take call periodically, your elective practice isn't going to generate a lot of disasters, so don't be put off by that. Most breast fellows I know wanted a job with no gen surg call and most who were willing to be open minded about geography found one.

Money wise, starting salaries on the offers I heard about for those that joined groups were at least comparable to gen surg onc positions to perhaps up to 10% less (when comparing within institutions), so you won't go hungry for sure. Again, those that must live in one locale, especially big desirable cities, often had a harder time negotiatinig this though. Also, if you join someplace where you aren't allowed to do image guided stuff, you might take a bigger hit financially unless you are extremely busy either in the clinic or in the OR.

Hope this helps you make your decision.
 

Winged Scapula

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I don't have much to add to the excellent comments above, so I will make some general comments:

1) Pay - it can vary wildly; for those willing to answer from my class, the range was $150 - $325K/year. The low end was for someone who essentially felt locked into a certain geographical area and HAD to take what was offered. "They" knew it and lowballed her.

I make more than the average general surgeon, take no general surgery call and in a year in practice have very, very rarely gotten a call afterhours or on the weekend which required me to do anything more than give advice/order over the phone. As a matter of fact, I am trying to remember if I ever have.

At any rate, like most things, your pay will depend on your negotiating skills and your flexibility. I was able to say *&*^ you to people who lowballed me because I had no geographical restrictions (other than I wanted to be in a big city and be warm).

PP will pay more, in most cases, than university hospitals. Many community breast centers want a fellowship trained breast surgeon to be their medical director and you can be handsomely rewarded for this.

The key, as noted above, is volume. And the key to volume is efficiency. We don't learn this in residency. I have learned to try and book my cases at the hospitals where the turn over time is short, where I have less paperwork to fill out, where the staff is motivated and the drive there is shorter. I can do 10 cases in a day if everything flows smoothly. Don't believe your academic surgeons who tell you you can't make money doing breast...I was told the same story by my faculty. They have the academic mindset in which they have no motivation to do 10 cases a day and don't do image guided biopsies.

2) Image guided biopsies...I make more doing an ultrasound guided biopsy in the office than I do a mastectomy; I could do one of the former in less than 1/5 of the time of the latter all without leaving the office.

Even better is placement of brachytherapy catheters. Some surgeons don't place these in the office but rather do it in the operating room. Money left on the table as you lose the facility fee. I have 3 of these scheduled for December 2. I will make more in that one day than I made my entire first month in practice by doing that procedure.

Needless to say this is an important skill to have and should be heavily weighted in your choice of a fellowship if you aren't interested in academics. You must also assess the local environment; some communities are heavily radiology influenced and you will have a had time getting your foot into the door to do the biopsies. My area was great; the surgeons had set a precedence for doing them.

3) Gender - it is true that some patients will prefer females. But most breast surgeons are still male and while you may miss out on some referrals if there is a female surgeon close by, if you market yourself and take good care of patients you will probably do well.

4) Call - Very few breast fellowship trained surgeons want to take general surgery call. droliver notes that this is a problem at some hospitals and this is true. I know one of the local hospitals here where I'd planned on getting privileges changed their bylaws to require all general surgery trained surgeons to take call. A bit disappointing but frankly I'm in a large city and there are tons of other hospitals that don't require it.

One must be careful when interviewing for a job to assess this issue if its of importance to you. A practice has no control over what local hospitals require. So just because you may be hired without having to take general surgery call, if you can't find a local hospital that will give you privileges without taking it, then you are SOL. Thus, make sure when considering a PP or community practice that you assess the local temperment and requirements before signing. For me, GS call was a "walk away" point in contract negotiations and jobs that couldn't guarantee it, fell off my list.

Needless to say, I think its a great field - great patients, lots of face to face time with them, multidisciplinary and lots of work without the lifestyle issues of surg onc.

However, the patients are very very needy. Missing a breast cancer is the number #1 reason for malpractice suits so everyone is on edge. Breast patients will sue you; your Whipple patients won't. You have to slog through the inevitable breast pain and the patients with normal clinical and radiologic exams because someone "wanted to be sure" or didn't know what normal was. It can be hard to have a cancer only practice when you start - you have to take everything.

I agree that you shouldn't do a surg onc fellowship if you are only planning on doing breast; most surg onc programs include on 6-8 weeks total on breast. Its highly academic of course. It WOULD give you more options if you changed your mind during training.

At any rate, this is pretty rambling...darn lifestyle specialty, I haven't been home before 800 pm once this week, so I'm tired.:p
 
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cncrsrgry

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Sorry for the late thank you but THANKS!

I definitely feel that a breast fellowship makes more sense for me.

Quick question about image guided biopsies :

Do you need to be certified in US or stereotactic core biopsy in order to bill insurance companies for them? Or for a screening/diagnostic US? If so, who certifies you?

Do surgeons do MRI guided biopsies?

While it seems that most breast fellowships provide some ultrasound and US guided bx that you could probably take with you to practise, most do not teach stereos or MRI guided stuff.

If this is the case, it would seem important to learn these quickly once out of fellowship, perhaps even taking less money to find a practise where you can learn these techniques and get certified in them. You could then either stay or go and find a practise where you could use these skills and do well.

Obviosuly, mammosites are important to learn too.

Am I overstressing the value of these office based procedures?

It seems they are critical to running a profitable practise and that accepting a seemingly great job with good initial pay without learning these skills upfront is shortsighted. After your initial big guarantee runs out (usually 1-3 years) and your salary is based on production, knowing how to do those procedures in a place where you are encouraged to do them seems critical.

THANKS AGAIN.
 

Winged Scapula

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Sorry for the late thank you but THANKS!

I definitely feel that a breast fellowship makes more sense for me.

Quick question about image guided biopsies :

Do you need to be certified in US or stereotactic core biopsy in order to bill insurance companies for them? Or for a screening/diagnostic US? If so, who certifies you?
Currently there is no standardization across the board requiring certification. The American Society of Breast Surgeons has set up certification programs in the event that this does come to pass. There is one local hospital here that starting making some mutterings about wanting us to be certified or at least meet ACR requirements (which are only 12 stereos, so not a problem for my partner and I prove we've done that many).

So, no...no one is requiring you to be certified to bill. If you are able to get privileges at hospitals to do them, then you can bill. Of course, getting privileges requires that either you were trained during fellowship to do them (which you won't be) or can find a local surgeon to supervise you for a few (its generally not many the hospitals require). Things may change as we are clearly heading toward a more restrictive environment in regards to procedures.

I do not do diagnostic or screening ultrasounds. IMHO that's too much medical liability. I can read an ultrasound, I can do one to localize a mass, assess the feasibility of biopsy and to perform the biopsy. But a good whole breast ultrasound takes a long time and doesn't pay well..its a waste of your office time when you could be seeing another new patient for more money. Secondly, the legal liability worries me. If you feel differently, that's up to you, but it doesn't seem worth it to me.

Do surgeons do MRI guided biopsies?
Again, it depends on the community. We have a dearth of even radiologists here in town who do them and do them well, so we've been asked if we want to learn. We haven't had time to figure out what the reimbursement is and if its worth traveling to the places that have MRI guided biopsy capabilities, but at least for us, we have radiologists that have floated the idea. I suspect this is unusual as there is a fair bit of animosity over this in many places around the country.

While it seems that most breast fellowships provide some ultrasound and US guided bx that you could probably take with you to practise, most do not teach stereos or MRI guided stuff.
I would change most to a few. Most programs DO NOT train you to do these biopsies with anywhere near enough practice to become facile. It is a HUGE issue for the SSO and there has been talk of "de-accrediting" programs that don't offer this training. Trouble is that this means defrocking the most ivy covered prestigious programs which doesn't look so good to have Big Name Hospital X as unaccredited.

Even fewer teach stereos or MRI guided biopsies (I couldn't learn - it was a political battle since we couldn't purchase the equipment for the cancer center and the uni hospital wasn't about to let us use theirs). Some programs have taken the extra step of sending you for an away rotation to community programs/private practices where you can train with some seasoned surgeons who do these in their practice. The issue tends to be licensing (as it can be hard to find someone in your state - my partner and I have expressed interest in doing such training, but no such formal program exists yet. But the ASBS and SSO are considering it).

If this is the case, it would seem important to learn these quickly once out of fellowship, perhaps even taking less money to find a practise where you can learn these techniques and get certified in them. You could then either stay or go and find a practise where you could use these skills and do well.
This is what I did. I took one of my lower offers because not only did I really like my partner as a person but because it offered me the opportunity of an apprenticeship in image guided biopsies, brachytherapy catheter placement, oncoplastics, etc.

Obviosuly, mammosites are important to learn too.

Am I overstressing the value of these office based procedures?
I don't think so...it gives you the advantage of being marketable anywhere. It is the KEY, IMHO, to a successful private/community practice and can even be useful in an academic practice. I learned my US guided biopsies because my fellowship director, at an academic practice, learned them and agreed with me that I/his fellows should be prepared for any type of practice. Besides, once you do these things, you find they're sort of fun and its very satisfying watching yourself get better at them. I used to be scared of lesions less than 1 cm (now I"m down to about 1-2 mm before I get nervous that I'll miss it).:D

Mammosites are easy, but consider Conturas instead. ;)

It seems they are critical to running a profitable practise and that accepting a seemingly great job with good initial pay without learning these skills upfront is shortsighted. After your initial big guarantee runs out (usually 1-3 years) and your salary is based on production, knowing how to do those procedures in a place where you are encouraged to do them seems critical.

THANKS AGAIN.
I couldn't have said it better myself. These skills are not brain surgery but they are valuable and you may find yourself outpaced if you don't do them. Some employers are expecting that you have these skills if others in the community have them. A recent grad of a big name fellowship took a job at a community hospital in a nearby state...little no name hospital was thrilled to have her with all those fancy degrees until they reportedly found out that she wouldn't recognize an US machine if it were sitting in the room with her. Don't let that be you.

If you find yourself in a program that doesn't adequately prepare you, consider talking to one of the following successful breast surgeons about an elective:

Mark Gittleman - Allentown
Beth DuPre - Philly area
Gail Lebovic - Dallas area
Peter Beitsch - Dallas area
Pat Whitworth - Nashville
C. Alan Henry - Roanoke
Lorraine Tafra - Anapolis