Hypothetical question:
What if I told you that I can do DIEP breast recon for your patients, but I don't accept insurance. And I am the only guy in the neighborhood who does perforator breast recon. Would you send me your patients? Or would you refer to the expander/implant crowd because they take insurance, even though I can do a more elegant and in many cases offer a superior result?
Sure I would refer patients to you; I don't believe its my decision about what type of reconstruction a patient should have. That's not my job. But a more elegant and "superior" result may not be what the patient wants or can afford.
There is a reason expander/implants are the most common choice outside of academia:
1) patients do not want such lengthy surgery
2) patients do not want an extended hospital stay
3) if you did take insurance you are paid hardly any more than you are for medical device recon (so PRS guys in PP won't do them - the only academic hospital we have here is Mayo and there are very few insurances they take)
4) many patients will not physically tolerate such a lengthy surgery (this is of course highly variable, as I have a lot of young and healthy patients) or are smokers
5) patients do not want more scars, or longer ones (there is quite a contingent who are obscenely focused on how long their scars will be, how many they will have)
But in response to your question, I will give patients information about the types of recon available to them and if your skills are what you purport them to be, I will tell patients what you can offer and give them your name. They can make the decision after seeing you and someone else what's best for them and what they can afford. It is not my decision and frankly, I want whatever they wish to have, as long as its medically sound.
Then I will ask WHY you won't take insurance and will tell you that you will lose business in the community because people, especially in this economy, don't have that kind of money to pay for, even in my area, recon. They will save for it for an aesthetic procedure but cancer cases are usually a suprise. IMHO surgeons don't take insurance for 1 reason: they want more money.
Obviously a hypothetical case but in academics we often get blinded by what we can do and don't think about what patients want or can afford. I see some excellent expander/implant reconstructions and patients are very happy with them. For most, IMHO, the trade offs are huge and they are not willing to spend the time and money for the DIEP/tissue recon.
What are you going to do/think when your beautiful DIEP has the crap radiated out of it? Rad Oncs are constantly increasing the "indications" for PMRT and with the increasing use of neoadjuvant chemo (at least in my population), they are almost always recommending PMRT "just in case" since they don't know what the axilla or size of the tumor was before Ctx. Its a real issue here locally; PRS guys aren't too happy about it.
Anyway, I have no problem sending patients to the best plastic surgeon but the above issues are real, and need to be recognized. Patients may not be able to afford your services; just because someone wants a Porsche doesn't mean they always get it - unfortunately. These women are at a crisis point in their lives and many of them are not willing or are unable to afford such an out of pocket expense. Regardless of your superior results I could not in good conscience tell them they need to go broke or take out a loan to do so. Unfair perhaps, but its the economic reality.
