Can someone tell me why plastic surgery is so competitive?

[bluedevski1992]

It seems as if it is similar to ENT and ortho in compensation, lifestyle, and in that they are all surgical subspecialties. Why is it the hardest residency to match?

Serious question. I am naive and curious. I also understand ENT and ortho are competitive.

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[Slack3r]

Cosmetics.

 

[TheWeeIceMan]

Money and boobs.

 

[bluedevski1992]

Cosmetics.

Money and boobs.

Actually? Would you say a good portion of those going into PRS do so to pursue cosmetics?

 

[NontradCA]

 

[bluedevski1992]

Can't tell if everyone is serious or if I'm being trolled.

 

[dadaddadaBATMAN]

It seems as if it is similar to ENT and ortho in compensation, lifestyle, and in that they are all surgical subspecialties. Why is it the hardest residency to match?

Serious question. I am naive and curious. I also understand ENT and ortho are competitive.

Disclaimer: I'm a second year medical student.

Cosmetic procedures are lucrative, because you can control the patient base. It's difficult to argue that a nosejob is necessary for health under many circumstances. You can charge cash, you can have rich patients, and CMS/government have more difficult controlling your purse strings.

I believe at least some plastics have call, but if you were running a purely cosmetic practice you might be able to avoid this (talking out of my ass here). I can't imagine anyone going "It's 2am and this woman needs a face-lift STAT!!!"

My understanding is that dermatology has many of these same benefits, provided you're practicing cosmetics. The residency for derm. seems less brutal.

@DermViser would be able to speak to this better than I can though, if interested.

 

[styphon]

$$$$, most plastics are not hospital based, therefore no call, no going in at night or the weekends...

 

[235009]

It's so competitive because there are so few residencies and the potential pay is good. That's why any specialty is competitive. Once the pay/outlook starts to slip or the number of residencies starts to increase the competition dissipates (see radiology).

 

[DrEnderW]

How competitive are plastics fellowships?

Is coming from a top GS program the main factor or do things like research/pubs play a larger role?

 

[Kahreek]

few spots
high pay
high glamour
manageable lifestyle after residency
but mostly the first two

 

[anon9301]

few spots
high pay
high glamour
manageable lifestyle after residency
but mostly the first two

like how much money

 

[Kahreek]

like how much money

huge amounts, think of ferraris.

 

[anon9301]

huge amounts, think of ferraris.

nice. looks like i found my answer to the "why medicine" question in interviews.

 

[Slack3r]

Actually? Would you say a good portion of those going into PRS do so to pursue cosmetics?

 

[notbobtrustme]

How competitive are plastics fellowships?

Is coming from a top GS program the main factor or do things like research/pubs play a larger role?

GS -> plastics is just as hard or harder than straight plastics.

 

[DermViser]

Disclaimer: I'm a second year medical student.

Cosmetic procedures are lucrative, because you can control the patient base. It's difficult to argue that a nosejob is necessary for health under many circumstances. You can charge cash, you can have rich patients, and CMS/government have more difficult controlling your purse strings.

I believe at least some plastics have call, but if you were running a purely cosmetic practice you might be able to avoid this (talking out of my ass here). I can't imagine anyone going "It's 2am and this woman needs a face-lift STAT!!!"

My understanding is that dermatology has many of these same benefits, provided you're practicing cosmetics. The residency for derm. seems less brutal.

@DermViser would be able to speak to this better than I can though, if interested.

Building up a huge cosmetics practice (at least for Derm) is harder bc you have other people doing it as well: IM, FM, OB-Gyn, Plastics, etc. For a full cosmetics practice it usually requires a lot of upfront capital and if you live in NYC or LA, you'll have a lot of competition. Most derms don't practice this way - as most of derms can't be the next Rodan and Fields.

But derms hours are just bc of the nature of the specialty. There really are not huge cases of "emergencies" per say, and in hospitals Derm is more a consult service for emergencies (SJS, etc.) that do come in.

 

[BestDoctorEver]

Is the average salary even in the 300k? I remember seeing somewhere that the average is less than that... I don't understand why it is so competitive as well.

 

[RJGOP]

Good lifestyle after residency. Pretty much guaranteed 350k a year. In certain areas, specifically areas with wealthy older people, you could make several million a year. Some 'prestige' with the title, although not tangible some people like it. Honestly plastics isn't my cup of tea, at least not as of now, but I can see why people would like it.

 

[IJL]

 

[KinasePro]

Never understood why anyone would want to do cosmetics... that's the worst patient population hands down. I'd rather deal with the schizophrenic guy eating his own poop (seriously saw this once) than the soccer mom seeking her 5th plastic surgery.

I understand the recon aspect, which is truly baller. And hand is sweet too. But cosmetics? No thanks, jeff.

 

[tdram]

Never understood why anyone would want to do cosmetics... that's the worst patient population hands down. I'd rather deal with the schizophrenic guy eating his own poop (seriously saw this once) than the soccer mom seeking her 5th plastic surgery.

I understand the recon aspect, which is truly baller. And hand is sweet too. But cosmetics? No thanks, jeff.

Look man if you're doing to deal with annoying people, might as well get paid handsomely for it.

 

[RJGOP]

Never understood why anyone would want to do cosmetics... that's the worst patient population hands down. I'd rather deal with the schizophrenic guy eating his own poop (seriously saw this once) than the soccer mom seeking her 5th plastic surgery.

I understand the recon aspect, which is truly baller. And hand is sweet too. But cosmetics? No thanks, jeff.

Jesus dude. Where the hell did you see that? Sounds like a nightmare case where they lock him up in the looney bin.

 

[KinasePro]

Look man if you're doing to deal with annoying people, might as well get paid handsomely for it.

I sort of understand that rationale, but if that's your philosophy, where's your self respect? The schizophrenic seriously needs advanced medical expertise and will get better with treatment. The soccer mom honestly needs a reality check, but instead you just end up nurturing her insecurities.

Not hating on PRS as a whole, just the 100% cosmetic PRS. I know some awesome PRS surgeons who would love to go full recon but have to keep the lights on with some cosmetics.

Jesus dude. Where the hell did you see that? Sounds like a nightmare case where they lock him up in the looney bin.

Inpatient psych at a large county hospital. A memorable rotation to say the least...

 

[BestDoctorEver]

Good lifestyle after residency. Pretty much guaranteed 350k a year. In certain areas, specifically areas with wealthy older people, you could make several million a year. Some 'prestige' with the title, although not tangible some people like it. Honestly plastics isn't my cup of tea, at least not as of now, but I can see why people would like it.

I guess it's time to study harder and aim for a 260+ in step1 ...

 

[PiBond]

I'm applying to plastics this cycle and here's my (humble) understanding behind its competitiveness. This isn't an exhaustive list by any means:
- After you get out of training, you have the ability to make your practice what you what. Like breast reconstruction? You can do flaps all day and make a great living. Like hand surgery? You'll be in high demand in many places and make good money (although the call can be tough). Like pediatric craniofacial? There's opportunity there too and is actually fantastic for those surgeons who enjoy continuity of care as many patients will require multistage reconstruction over the course of their childhood/adolescence. Want a hybrid academic/private practice? Want 9-5 hours? Want to teach residents? Want to operate under a microscope? Yada yada yada. You get the point...there are a lot of options and the operative variety was a draw for the majority of all of the plastic surgeons I've worked with.
- Truly amazing surgeries that require high technical skill. Personally, plastic surgery was the only thing that ever blew my hair back in medical school (although delivering babies was cool to0). I've gathered that most plastic surgeons in practice aren't bored with the surgeries they perform (although some may get tired of a certain patient population, namely cosmetic patients) and continue to enjoy their work even after years of operating
- Vast array of patient ages and whole-body anatomy--they get to operate on every age and from head to toe
- Novelty of cases, intellectually challenging, opportunity to go abroad for mission work, etc

I will say that my plastics rotations have been some of my hardest rotations in medical school and the residents/attendings work harder than I ever knew possible. It's a tough 6-7 year residency and really stretches your limits if you go to a high-volume program. The longest surgeries, toughest hours, and most complex cases have all been on my plastics rotations but it's been the most amazing and mind-blowing experience I've ever had in medicine. Even if you aren't going into surgery, I recommend you try to do a rotation in the field as it's one of the most misunderstood specialities in my opinion and will give you an immense appreciation for the field of reconstructive surgery.

 

[DermViser]

I'm applying to plastics this cycle and here's my (humble) understanding behind its competitiveness. This isn't an exhaustive list by any means:
- After you get out of training, you have the ability to make your practice what you what. Like breast reconstruction? You can do flaps all day and make a great living. Like hand surgery? You'll be in high demand in many places and make good money (although the call can be tough). Like pediatric craniofacial? There's opportunity there too and is actually fantastic for those surgeons who enjoy continuity of care as many patients will require multistage reconstruction over the course of their childhood/adolescence. Want a hybrid academic/private practice? Want 9-5 hours? Want to teach residents? Want to operate under a microscope? Yada yada yada. You get the point...there are a lot of options and the operative variety was a draw for the majority of all of the plastic surgeons I've worked with.
- Truly amazing surgeries that require high technical skill. Personally, plastic surgery was the only thing that ever blew my hair back in medical school (although delivering babies was cool to0). I've gathered that most plastic surgeons in practice aren't bored with the surgeries they perform (although some may get tired of a certain patient population, namely cosmetic patients) and continue to enjoy their work even after years of operating
- Vast array of patient ages and whole-body anatomy--they get to operate on every age and from head to toe
- Novelty of cases, intellectually challenging, opportunity to go abroad for mission work, etc

I will say that my plastics rotations have been some of my hardest rotations in medical school and the residents/attendings work harder than I ever knew possible. It's a tough 6-7 year residency and really stretches your limits if you go to a high-volume program. The longest surgeries, toughest hours, and most complex cases have all been on my plastics rotations but it's been the most amazing and mind-blowing experience I've ever had in medicine. Even if you aren't going into surgery, I recommend you try to do a rotation in the field as it's one of the most misunderstood specialities in my opinion and will give you an immense appreciation for the field of reconstructive surgery.

Correlating post with avatar...

 

[mystical man]

Mcsteamy


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[Kahreek]

I'm applying to plastics this cycle and here's my (humble) understanding behind its competitiveness. This isn't an exhaustive list by any means:
- After you get out of training, you have the ability to make your practice what you what. Like breast reconstruction? You can do flaps all day and make a great living. Like hand surgery? You'll be in high demand in many places and make good money (although the call can be tough). Like pediatric craniofacial? There's opportunity there too and is actually fantastic for those surgeons who enjoy continuity of care as many patients will require multistage reconstruction over the course of their childhood/adolescence. Want a hybrid academic/private practice? Want 9-5 hours? Want to teach residents? Want to operate under a microscope? Yada yada yada. You get the point...there are a lot of options and the operative variety was a draw for the majority of all of the plastic surgeons I've worked with.
- Truly amazing surgeries that require high technical skill. Personally, plastic surgery was the only thing that ever blew my hair back in medical school (although delivering babies was cool to0). I've gathered that most plastic surgeons in practice aren't bored with the surgeries they perform (although some may get tired of a certain patient population, namely cosmetic patients) and continue to enjoy their work even after years of operating
- Vast array of patient ages and whole-body anatomy--they get to operate on every age and from head to toe
- Novelty of cases, intellectually challenging, opportunity to go abroad for mission work, etc

I will say that my plastics rotations have been some of my hardest rotations in medical school and the residents/attendings work harder than I ever knew possible. It's a tough 6-7 year residency and really stretches your limits if you go to a high-volume program. The longest surgeries, toughest hours, and most complex cases have all been on my plastics rotations but it's been the most amazing and mind-blowing experience I've ever had in medicine. Even if you aren't going into surgery, I recommend you try to do a rotation in the field as it's one of the most misunderstood specialities in my opinion and will give you an immense appreciation for the field of reconstructive surgery.

holy hell, someone got their panties in a bunch

 

[tdram]

I did a plastics rotation. Many of the surgeries were done mostly by the PA while the attending just chilled out and jumped in once in a while.

 

[DermViser]

I did a plastics rotation. Many of the surgeries were done mostly by the PA while the attending just chilled out and jumped in once in a while.

 

[operaman]

Agreed -- recons are some of the most amazing surgeries. There's always that moment right after the resection as the teams are changing out where I can't imagine how we're going to put humpty dumpty back together again. But they do. And it's f-ing awesome.

But mostly I think it's the number of spots. There is good money to be made in many other competitive subspecialties, but plastics has the fewest positions.

 

[tdram]

True story. She was only 3 years out of PA school, and the attending was giving her a lot of freedom to operate. She seemed to be doing a good job, though I would have no way to be sure.

 

[username456789]

holy hell, someone got their panties in a bunch

You either misread the entire post/missed the tone, or don't understand what that saying means.

 

[RJGOP]

True story. She was only 3 years out of PA school, and the attending was giving her a lot of freedom to operate. She seemed to be doing a good job, though I would have no way to be sure.

I'm sure the patient wouldn't appreciate that. What was the procedure?

 

[tdram]

I'm sure the patient wouldn't appreciate that. What was the procedure?

There were several procedures. She did breast augmentation and panniculectomy pretty much completely herself.

 

[operaman]

I hate to say it, but the PA who operates with our plastics people has better surgical skills than many of the junior residents (and certainly better than mine!).

 

[tdram]

I hate to say it, but the PA who operates with our plastics people has better surgical skills than many of the junior residents (and certainly better than mine!).

What is the point of residency if you can learn it better as a PA?

 

[operaman]

What is the point of residency if you can learn it better as a PA?

Well, the juniors (PGY-1/2/some 3s) haven't been operating that long while the PA has been doing it for 10+ years.

 

[tdram]

Well, the juniors (PGY-1/2/some 3s) haven't been operating that long while the PA has been doing it for 10+ years.

But the PA has never had any formal training in surgery.

 

[operaman]

But the PA has never had any formal training in surgery.

Except for spending 2-3 days /week in the OR with an attending who loves to teach and has taught her how to do the kinds of things she needs to do.

Then there's repetition: 2-3 big cases per week x 40 weeks operating each year x 10 years = 800-1200 BIG cases (probably more since those are conservative numbers).

And obviously she's operating with the attending present or at least available so she doesn't need the comprehensive training necessary to operate unsupervised.

 

[Kahreek]

You either misread the entire post/missed the tone, or don't understand what that saying means.

what?

 

[Winged Scapula]

The difference with the PA vs the residents (in this scenario) is that the PA is learning by repetition but doesn't have any graduated responsibility; if something goes to hell in a hand basket he/she always has the attending to bail them out. At some point the surgical resident will finish training and be independent, responsible for any and all outcomes.

They generally don't have the experience or knowledge/skills foundation to fix it when something goes wrong. It's like the junior resident claiming they're doing the Whipple when in reality the attending is guiding the dissection, having the resident cautery between the hemostat. "Doing" 1200 cases doesn't mean much if you aren't really doing them. FWIW primary breast augmentation and panniculectomies aren't considered very difficult cases in the grand scheme of things (he'll you have FPs and even dentists doing breast augs) AS LONG AS EVERYTHING GOES WELL. Anyone who's even done a reconstruction or even seen "Botched" can see that there are things that can go horribly wrong.

 

[Winged Scapula]

- After you get out of training, you have the ability to make your practice what you what. Like breast reconstruction? You can do flaps all day and make a great living.

A point of clarification (which may be colored by your medical school experience):

Most plastic surgeons outside of academia do not routinely do flap based breast reconstruction; almost none do free flaps. In addition, doing flaps does not lead to a "great living" in comparison to the better time investment to reimbursement of implant based reconstruction.

This is simply a matter of the time involved, the longer post operative inpatient recovery (for which you are not paid) when compared to the implant alternative. It doesn't make financial sense to do flaps in PP for the rates that insurance pays when you can do multiple implant recons for more money. I work with some fast plastic surgeons and they all agree that for the amount of time it takes to do a flap and the potential for intraoperative complications, implants are the best choice. When you also consider that most patients prefer implant reconstruction over flaps, you can see why these are almost never done except in the case of a failed implant reconstruction or in patients with contraindications to implants. Free flaps are simply out of the question given the instrument resources needed, operative staff and length of time to do.

 

[tdram]

The difference with the PA vs the residents (in this scenario) is that the PA is learning by repetition but doesn't have any graduated responsibility; if something goes to hell in a hand basket he/she always has the attending to bail them out. At some point the surgical resident will finish training and be independent, responsible for any and all outcomes.

They generally don't have the experience or knowledge/skills foundation to fix it when something goes wrong. It's like the junior resident claiming they're doing the Whipple when in reality the attending is guiding the dissection, having the resident cautery between the hemostat. "Doing" 1200 cases doesn't mean much if you aren't really doing them. FWIW primary breast augmentation and panniculectomies aren't considered very difficult cases in the grand scheme of things (he'll you have FPs and even dentists doing breast augs) AS LONG AS EVERYTHING GOES WELL. Anyone who's even done a reconstruction or even seen "Botched" can see that there are things that can go horribly wrong.

Dentists do breast augmentations???

 

[DermViser]

The difference with the PA vs the residents (in this scenario) is that the PA is learning by repetition but doesn't have any graduated responsibility; if something goes to hell in a hand basket he/she always has the attending to bail them out. At some point the surgical resident will finish training and be independent, responsible for any and all outcomes.

They generally don't have the experience or knowledge/skills foundation to fix it when something goes wrong. It's like the junior resident claiming they're doing the Whipple when in reality the attending is guiding the dissection, having the resident cautery between the hemostat. "Doing" 1200 cases doesn't mean much if you aren't really doing them. FWIW primary breast augmentation and panniculectomies aren't considered very difficult cases in the grand scheme of things (he'll you have FPs and even dentists doing breast augs) AS LONG AS EVERYTHING GOES WELL. Anyone who's even done a reconstruction or even seen "Botched" can see that there are things that can go horribly wrong.

Seriously!?!?

 

[operaman]

The difference with the PA vs the residents (in this scenario) is that the PA is learning by repetition but doesn't have any graduated responsibility; if something goes to hell in a hand basket he/she always has the attending to bail them out. At some point the surgical resident will finish training and be independent, responsible for any and all outcomes.

They generally don't have the experience or knowledge/skills foundation to fix it when something goes wrong. It's like the junior resident claiming they're doing the Whipple when in reality the attending is guiding the dissection, having the resident cautery between the hemostat. "Doing" 1200 cases doesn't mean much if you aren't really doing them. FWIW primary breast augmentation and panniculectomies aren't considered very difficult cases in the grand scheme of things (he'll you have FPs and even dentists doing breast augs) AS LONG AS EVERYTHING GOES WELL. Anyone who's even done a reconstruction or even seen "Botched" can see that there are things that can go horribly wrong.

Exactly.

 

[Winged Scapula]

$$$$, most plastics are not hospital based, therefore no call, no going in at night or the weekends...

This is fairly inaccurate.

1) all plastic surgeons have to take call for their own practice; someone has to answer the phone calls from patients after hours, on weekends
2) plastic surgery patients, even the reconstruction ones ("they all become cosmetic patients" Dr. MW, 2013 personal communication), are very needy and will call for any and everything
3) plastic surgery patients may not follow instructions and end up with complications, leading them to the ED and perhaps, back in the OR (I rarely watch medical shows anymore but one of the reasons I love "Botched" is that it accurately shows how difficult these patients can be)
4) some hospitals require ED call as part of having privileges there; so a plastic surgeon will often be called to a) repair a facial lac on a child or anyone else who requests it, crosses the vermillion border, etc b) to see a facial fracture or hand injury (in many places PRS shares this call with ENT and Ortho)
5) hospital consults; no one cares/thinks about whether it's after hours or the weekends even for chronic problems.
6) if one of your patients is having a problem, you are going in at night. I went in last night to see one of my patients who dropped her pressure to 60; the plastic surgeon joined me there as well to make sure she was as ok and didn't need a return to the OR
7) patients don't always go home before the weekend, even planned outpatient procedures; patients classically sit on a problem at home until Friday PM so a nighttime or weekend consult or admission aren't unheard of
8) even if you have "Courtesy Call" (ie, not required) you will still get called from the ED and the hospital for consults; you say "no" too often and you will see your referrals dwindle

So while a 100% aesthetic practice can eliminate some of the above (ie, you probably won't have privileges are hospitals that require ED call), it would be an overstatement to say that PRS doesnt have call. Or going in at night or on the weekends (I just finished rounds with my plastic surgeon; she'll be going in tomorrow as well to see one of her post op flaps).

 

[Winged Scapula]

Seriously!?!?

Yes.

In the US it's usually DMDs who possess a medical license but have not done a surgical residency. Same for FPs. People operating outside of their scope of practice to make a buck is sadly, not uncommon.

But there have been cases of dentists doing breast augs and other cosmetic procedures without a medical license. This has been a problem outside of the US as well: http://www.smh.com.au/national/heal...gery-plastic-surgeons-say-20130309-2fsec.html

 

[styphon]

Seriously!?!?

How do I get in on that