PRS versus FPRS

[ghatz]

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Hello all,

I'd like to have your opinions on the pro's and cons of doing an Integrated PRS program versus an Otolaryngology + FPRS fellowship with the goal of practicing as a private cosmetic plastic surgeon.

For the sake of reducing the variables, let's say we want to compare a PRS surgeon who mainly does face cosmetics with a FPRS surgeon.

Besides the "who's more qualified" discussion, please weigh in on other factors eg ease of obtaining privileges, rigor of training, life as resident, income, work hours, future, etc.

I would appreciate your comments and please no bashing of either specialty- Just respectful discussion.

Thanks 🙂

 

[ghatz]

has this question been answered before? because I cannot find anything...

 

[Pir8DeacDoc]

Pretty sure you're the first person to ask 🙂


If you want to be a cosmetic surgeon, why waste your time doing a full ENT residency? Lots of stuff in ENT not at all related to your desired career. Further, I think it's likely a lot harder for a facial plastics guy to ONLY do facial plastics (especially initially out of fellowship). I get the sense that a lot of facial plastics folks practice general ENT with a focus on facial plastics stuff. Those who can do only facial plastics are somewhat few and far between.

 

[ghatz]

Thanks for the reply! How are the lifestyles different? Hours, income, etc.. during residency AND beyond.. Thanks!

 

[maxheadroom]

Thanks for the reply! How are the lifestyles different? Hours, income, etc.. during residency AND beyond.. Thanks!

1. Your status says "Resident" which must not be true, since you're asking questions like this.

2. Please don't pursue either type of training if your questions are money, lifestyle, and how to obtain an all aesthetic practice. Neither group wants you.

3. Do a Family Medicine residency, take a weekend laser course, and go set up some crap Medi-Spa and leave the surgery to the real surgeons.

 

[ghatz]

So nice of you to enlighten me. If you weren't so one-dimensional about YOUR idea of a "real surgeon," you would have realized that even "real surgeons" have to get certain "real life" questions answered. You can deny it and go for what you think makes you a "real surgeon," according to whatever standards; but you have no right to question other peoples' motives or reasons, let alone questions. Perhaps your mind cannot see a world beyond the four walls of the wards.

Besides training, which I did ask about by the way, lifestyle figures greatly into the choice of specialty. There are several well known studies regarding these important factors that impact specialty choice.

I will leave it at that- since your answer was both useless and self-righteous. Don't give yourself a headache trying to write up a well thought out, intelligent sounding response, Real Surgeon.

 

[maxheadroom]

Always glad to help!

BTW, as a Plastic Surgeon I have an interest in making sure that the people who come into my specialty have a greater interest than pure aesthetic practices and big bucks.

 

[asmallchild]

As a headsup, lying about being a resident isn't going to be well-received anywhere.....

 

[ItalianPlastics]

So nice of you to enlighten me. If you weren't so one-dimensional about YOUR idea of a "real surgeon," you would have realized that even "real surgeons" have to get certain "real life" questions answered. You can deny it and go for what you think makes you a "real surgeon," according to whatever standards; but you have no right to question other peoples' motives or reasons, let alone questions. Perhaps your mind cannot see a world beyond the four walls of the wards.

Besides training, which I did ask about by the way, lifestyle figures greatly into the choice of specialty. There are several well known studies regarding these important factors that impact specialty choice.

I will leave it at that- since your answer was both useless and self-righteous. Don't give yourself a headache trying to write up a well thought out, intelligent sounding response, Real Surgeon.

I agree...lifestyle was a huge deciding factor for me when I chose plastics, though your life as a resident is just that--a resident!!! i think the plastics guys at my program work harder than the Gsurg guys, but you have much more freedom to tailor your lifestyle on the other end. But as in anything else, you get what you work for. If you want to make serious CA$H, you're gonna work for it. If you're satisfied with a very good living, you can work more decent hours and take it home to the family (and actually leave work!). That being said, no one likes a team-member who drops the ball on their work so make sure in whatever you do, work-hard, play hard!!

 

[...to_the_OR!]

So nice of you to enlighten me. If you weren't so one-dimensional about YOUR idea of a "real surgeon," you would have realized that even "real surgeons" have to get certain "real life" questions answered. You can deny it and go for what you think makes you a "real surgeon," according to whatever standards; but you have no right to question other peoples' motives or reasons, let alone questions. Perhaps your mind cannot see a world beyond the four walls of the wards.

Besides training, which I did ask about by the way, lifestyle figures greatly into the choice of specialty. There are several well known studies regarding these important factors that impact specialty choice.

I will leave it at that- since your answer was both useless and self-righteous. Don't give yourself a headache trying to write up a well thought out, intelligent sounding response, Real Surgeon.

Relax... he was simply emphasizing that PRS and FPRS are much broader than cosmetics. Every year we sort out the applicants that only have a superficial "cosmetic" interest. PRS specifically is the most diverse field in medicine and if all an applicant is interested in is cosmetics, then that DIEP, or that synostosis reconstruction, or the 10 hr pan-facial fracture case, or your 4th month on Hand is really gonna suck and you will be unhappy. Cosmetic cases are fun and obviously pay well, but you can't be a good aesthetic surgeon if you are not a great all around PRS surgeon.

BTW... lifestyle varies by program, but all surgical training is busy. If it is slow then you are not learning, and you only have so many years until you are alone in the OR and can't figure out where the bleeding is coming from and it wont stop... Surgical training is intense, it needs to be. But most PRS programs I looked at had married residents and residents with relatively normal social lives. There are a few brutal ones, but as a rule PRS has nearly as many hrs as other surgicAL specialties but less 2am emergencies. As an attending schedule is dependent on how your practice is setup. There might not be a ton of middle of the night stuff, but free flaps can go long and might need to go back. Even a cosmetic practice with a little breast recon and mohs recon on the side can go 7a to 7p if thats how you set it up. If you make people wait to get worked on they can go 2 blocks down to Dr. PRS#2.

 

[...to_the_OR!]

.

 

[ghatz]

Thank you guys I appreciate the responses. I am currently a prelim in G surg.. Last year did not match into Plastics but this year I was in on a couple of nice FP cases which led to my original question. I am aware of the diversity of the field, I simply asked to focus answers on cosmetics because that's what most FPs do so I wanted to compare apples with apples. Again, thanks.

 

[deleted144060]

I've said this in a couple of other threads, but I feel the need to say it again.

If you're concerned about lifestyle and money, go into anesthesia, radiology or business school.

I spend an inordinate amount of time doing non-surgery stuff. Granted some of it is related to being in academics, but the rest of it is universal. There's dictations, reading transcriptions of dictations, referral letters, phone calls, committee meetings, billing, coding, letters to insurance companies, more letters to insurance companies, frustrations with not getting paid, taking call at every hospital where you have admission privileges, and more. I spend almost every saturday catching up on all the paperwork that accumulated during the week while I was busy operating.

You say you'll be able to make enough money to hire people to help? That's great, except you're going to have to work even harder to pay them. And guess what? You generate even more paperwork. It really is ridiculous how much time gets sucked away by non-patient care activity.

If you're now thinking that Moravian is just a crabby old guy who's bitter about his career, you'd be wrong. I love what I do. It's the only reason I put up with all the other crap. And therein lies the lesson. If you don't really like what you do, the system as is stands now will make you miserable. Money and social standing do not abrogate that simple fact. Do plastics because you have the passion, not because of some imagined great life you'll have based on what you see on television.

--M

 

[ghatz]

Thanks Dr. Moravian and I appreciate your comments. I don't know how this thread led to something about lifestyles in general. I had simply but specifically asked for a comparison of lifestyles during PRS and ENT+FP residencies and beyond. So questions of prestige, doing anesthesia, etc don't really figure in. But I see everyone's points

 

[maxheadroom]

I've said this in a couple of other threads, but I feel the need to say it again.

If you're concerned about lifestyle and money, go into anesthesia, radiology or business school.

I spend an inordinate amount of time doing non-surgery stuff. Granted some of it is related to being in academics, but the rest of it is universal. There's dictations, reading transcriptions of dictations, referral letters, phone calls, committee meetings, billing, coding, letters to insurance companies, more letters to insurance companies, frustrations with not getting paid, taking call at every hospital where you have admission privileges, and more. I spend almost every saturday catching up on all the paperwork that accumulated during the week while I was busy operating.

You say you'll be able to make enough money to hire people to help? That's great, except you're going to have to work even harder to pay them. And guess what? You generate even more paperwork. It really is ridiculous how much time gets sucked away by non-patient care activity.

If you're now thinking that Moravian is just a crabby old guy who's bitter about his career, you'd be wrong. I love what I do. It's the only reason I put up with all the other crap. And therein lies the lesson. If you don't really like what you do, the system as is stands now will make you miserable. Money and social standing do not abrogate that simple fact. Do plastics because you have the passion, not because of some imagined great life you'll have based on what you see on television.

--M

Listen to Moravian! Listen! He's a smart guy . . . even though he got suckered into doing Funny Lookin' Kids in an academic practice. 🙂

(Nothin' but love for you, Moravian)

The super-high end Cosmetic guys work pretty darn hard. Their practices have a HUGE overhead. You need multiple patient-coordinators, a spa-atmosphere, and all sorts of trappings of luxury to compete with those guys. I have an aquaintance who joined a Big Name cosmetic guy . . . the practice overhead was something around 75%!!

Plastic surgery is NOT a lifestyle specialty. It's better than Ortho & Neurosurg, but ENT and Urology beat us most of the time for hours and call. If you want a real lifestyle practice in Plastics, you have to either prostitute yourself out to do LifeStyle Lifts (TM) or you can join a group like Kaiser (which isn't a bad gig, but doesn't pay great).

 

[mellen5]

i am a new member, and i am quite sure that the following statement will either be viewed as naive or hopeless, but bear with this post. i am currently a PGY 2 in general surgery with one plastics research project under her belt, with less than stellar board scores thus far...not terrible but very average. i am concerned about not loving the "bread and butter" general surgery cases and am considering changing specialties. i plan on spending most of my practice abroad doing missions, and since beginning medical school have realized the value of reconstructive surgical training for those without our first class medical care. you can give someone back their occupation, even social acceptance with the work you do.

long story short. with all your talk about lifestyles and cosmetics, i am skeptical about being accepted into a plastics program either integrated or as a fellowship following general training. this is secondary to the presence of so many qualified peers who look far better than i on paper, despite my desire to work hard and motives different from most. my question: is it a futile wish to be accepted into a plastics program?

 

[Stare Decisis]

During the application process this year I have been told that most integrated programs tend to look favorably on students who have interests outside of the cosmetic arena. The problem is that I have met several students who are genuinely interested in reconstruction and have the "numbers" as well. Several program chairman have insinuated that some "dues" should be paid in reconstruction before jumping ship to aesthetics. Maybe it makes you a better surgeon or maybe they don't want the added competition for those valuable cosmetic patients. I tend to agree with you about reconstruction and it appeals to me more than cosmetic surgery alone.

 

[maxheadroom]

Two different old-school academic Chairmen (and past ASPS Presidents) have given me the same talk about how they think things should work.

1. For the first ten years you take lots of call, do hand & maxillofacial trauma, do lower extremity free flaps, and take care of the wounds.

2. For the next ten years you do a lot of elective reconstruction, breast reductions, and start building an aesthetic practice.

3. For the last ten years you do primarily aesthetic surgery.

They complained about the newer generation of surgeons who market aggressively and work towards a pure cosmetic practice from the very beginning. The problem is that when they came up, trauma and recon paid really well. Even if you were getting your ass kicked, you were making pretty good money doing it. Now, you're lucky if half of the patients that you see in the ED have any sort of insurance. If they do have insurance, their insurer does everything possible to not pay you.

The other thing is important. Do you know who's really, really hurting right now? The non-big name all-aesthetic guys. Rohrich, Lambros, Stuzin, Barton, and their buddies have seen a slow down, but their schedules are still full (per people who would know). It's the junior guys who have been pushing really hard to do nothing but boobs, faces, and noses who suddenly have very little business. While Recon doesn't pay as well as Cosmetic, even in a recession people need their carpal tunnel release or to get that melanoma taken off. My friends who do primarily Recon really haven't noticed a dip in their collections.

 

[Stare Decisis]

This brings up a question I have concering some of the big name cosmetic surgeons. I have had the opportunity and privelege to scrub in with a couple of big names in academic cosmetic surgery around the country and I wonder how private cosmetic guys can compete. For instance, I have seen some of these guys routinely do 6 hour deep SMAS face lifts, long rhino cases, and augmentation mammoplasties. Then I hear the fellows discuss job hunting and how you are expected to do a facelift in 2.5 hrs and an aug in 45-50 minutes in these group practices. Are the results from these two different worlds similar? Or are they close enough that only trained plastic surgeons can appreciate the differences and patients do not care? How easy is it to switch from how you were trained to how you are expected to perform in these group models?
I initially thought junior private cosmetic surgeons just charged less, but how is this possible when they have so much overhead.

On the other hand, I have been told that it is better business model is to have one surgery you do well and compensates well. For example, carve out a niche for rhinoplasty/facelift/breast during your first 15 years then as you mature and build a referral base then concentrate on that area. He felt plastic surgeons maintained too broad of a practice for too long and became a "jack of all trades but master of none."

 

[Pir8DeacDoc]

Thank you guys I appreciate the responses. I am currently a prelim in G surg...

I thought you were an oto resident at a prestigious Northeast program looking to swap into integrated PRS??

 

[ghatz]

I thought you were an oto resident at a prestigious Northeast program looking to swap into integrated PRS??

correct, yet still a g surg prelim, like all other oto residents in their pgy1 year .. i think by prelim you assumed i meant non-designated prelim.

 

[Pir8DeacDoc]

The intern year in Oto is controlled by your ENT division/department. While in the past it was technically a prelim year, it is no longer a prelim year. There are certain requirements that the Oto RRC requires of the intern year, including anesthesia, NSurg, etc which aren't generally covered in the traditional general surgery prelim year.


I am finding it a little hard to believe that you applied and failed to match in integrated plastics but somehow managed to match at a prestigious Northeast program for Oto. I take it you applied to both Integrated plastics and ENT? The rare person considers ENT as a back up for plastics.

 

[ghatz]

Thanks for your response. As a PGY-1 ENT categorical resident you continue to be under the supervision of Gen Surg in most places although the ENT dept/div dictates completion of the RRC required rotations. You should know that, all programs around Boston are the same- and were the same three years ago too. Regardless, a PGY-1 ENT resident is essentially a gen surg "designated prelim."

Re your 2nd paragraph, yes I applied to both. Sorry can't help you believing it though, but I don't see how it affects you answering the question I originally posted.

 

[droliver]

Two different old-school academic Chairmen (and past ASPS Presidents) have given me the same talk about how they think things should work....They complained about the newer generation of surgeons who market aggressively and work towards a pure cosmetic practice from the very beginning. The problem is that when they came up, trauma and recon paid really well.

Agree 100%. It's a different era, and real reimbursements have fallen 70%+ for most of the procedures those guys made their name doing in the 1970's & 1980's. A practice that is not subsidized finacially or by labor (running multiple rooms with residents) by an institution will literally go broke doing 100% recon.

While Recon doesn't pay as well as Cosmetic, even in a recession people need their carpal tunnel release or to get that melanoma taken off. My friends who do primarily Recon really haven't noticed a dip in their collections.

Well, you can only run so fast on the hampster wheel before it falls apart. There is no way to significantly increase productivity with complex reconstructive surgery so as to grow or remain revenue neutral for most practices. They're just aren't enough hours per day.

In the background is the coming 21% Medicare reduction (which may or may not get delayed) in procedural and surgery fees which is an effective 30% reduction when it's accounted for in your practice. In Alabama for instance, Blue Cross (whom controls 92% of private insurance) has announced they're unilaterally redistributing their RVU's Dec 1 such as to produce a 20% across the board cut in surgery RVU's. That puts your monopoly private payor group at Medicare rates as well which is unsustainable unless I get to roll my rent, payrole, and malpractice rates back to 1970's #'s.

 

[igap]

The intern year in Oto is controlled by your ENT division/department. While in the past it was technically a prelim year, it is no longer a prelim year. There are certain requirements that the Oto RRC requires of the intern year, including anesthesia, NSurg, etc which aren't generally covered in the traditional general surgery prelim year.


I am finding it a little hard to believe that you applied and failed to match in integrated plastics but somehow managed to match at a prestigious Northeast program for Oto. I take it you applied to both Integrated plastics and ENT? The rare person considers ENT as a back up for plastics.

It is hard to believe that ENT would be a back-up. I actually know a guy at my institution who is an ENT resident and did exactly that. It speaks to the competitiveness of PRS.

Also, to be fair to the OP, although the ENT interns are lumped in with all of the "surgery interns", they are still referred to as "prelims" by many. They are not generally referred to as "general surgery prelims" though.

 

[igap]

Agree 100%. It's a different era, and real reimbursements have fallen 70%+ for most of the procedures those guys made their name doing in the 1970's & 1980's. A practice that is not subsidized finacially or by labor (running multiple rooms with residents) by an institution will literally go broke doing 100% recon.



Well, you can only run so fast on the hampster wheel before it falls apart. There is no way to significantly increase productivity with complex reconstructive surgery so as to grow or remain revenue neutral for most practices. They're just aren't enough hours per day.

In the background is the coming 21% Medicare reduction (which may or may not get delayed) in procedural and surgery fees which is an effective 30% reduction when it's accounted for in your practice. In Alabama for instance, Blue Cross (whom controls 92% of private insurance) has announced they're unilaterally redistributing their RVU's Dec 1 such as to produce a 20% across the board cut in surgery RVU's. That puts your monopoly private payor group at Medicare rates as well which is unsustainable unless I get to roll my rent, payrole, and malpractice rates back to 1970's #'s.

This sounds bleak. Is there any dialog in the state of Alabama about how this might affect access?

 

[Masoud309]

why not complete the ENT residency and then if still interested go for the PRS training? ENT is an approved pathway and many are successful ENT-trained PRS surgeons with serious leadership positions: thomas mustoe, jaime garza, samuel stal and several others.

 

[droliver]

This sounds bleak. Is there any dialog in the state of Alabama about how this might affect access?

All the specialty societies are screaming bloody murder but that is sound and fury signifying nothing for the most part. The problem is when you have such a single dominant insurer there is really no way to go non-par with them and continue to work in our state. In more diverse markets you might just drop that insurer, but you can't do that when the playing field is so distorted. That is one reason I strongly would endorse the ability to sell insurance across state lines. Unfortunately, I think that will also result in a race to the bottom with physicians fees.

Unfortunately, this squeeze is going to get worse with health care reform as it's being discussed. It's no longer of a question of whether will get screwed, it's a question of how hard. There is no mention in this debate on some windfall or financial assistance to practices, and everything from mandatory EMR's, bundled physician fees with hospitals, Stark Laws preventing entrepreneurship, and QA/RAC auditing will raise our overhead significantly. We're clearly moving towards a system where insurers will be paying medicare rates (or less), and I would be stunned if at somepoint we are not restricted by the feds or states from any out-of-network fee for service arrangements either as patients complain about access problems or about non-par MD's balance billling.

 

[Tristero]

I am a resident at a PRS program and would just like to echo the thoughts of DrOliver and Maxheadroom. My perspective is a bit biased as I hail primarily from Florida and California, where I would say the 10/10/10 rule is probably closer to 5/5/5.

This is just based off of PRS guys I know. Regardless, the guys who think they could go out, have a slick web site and do all cosmetic procedures are hurting badly across the board. And the guys with quality cosmetic practices (Stuzin is the guy I know) work damn hard.

The guys I know have more diverse insurance climates and are pretty well re-imbursed for their recon procedures; obviously not 1970/1980s rates but they seem pretty happy. Coding seems to be the critical factor with all the surgeons I talk to.

The medical landscape is frightening for surgical subspecialties. I do not think the 21% cuts will go through but it will be harder and harder to pay overhead with recon procedures ad as such, the aesthetic market will become more competitive.

This is not a game you want to play if you're interested primarily in making money. Is there money out there? Yes, but you have to work damn hard for it. But you have to work damn hard to make money in anything- whether its business, law, entrepreneurship.

Regarding the advice to switch into Rads or Anesthesia, my gut feeling is those are the fields that are going to see the deepest cuts, as they are vastly overpaid for what they do now. I dont think the ROAD lifestyles, outside of maybe optho (which has seen the majority of its cuts) and derm (which is just a small niche field) are going to be maintained much longer.

I don't know how much more cuts are going to come from surgical procedures, at least in PRS recon and ENT; these fields have already been deeply cut over the last 10 years and I am skeptical how much cost savings they would represent to cut them further.

When I looked over the Medicare cuts tables with Ron Davis (former president of AMA) about 3 years ago, I remember the deepest cuts being in Radiology.

Anesthesia is going to have serious supply/demand issues with the cRNA market. And Radiology faces serious issues with cuts to reads and increasing overhead/regulation of doctor owned centers.

Just my personal perspective; take it for what its worth.

 

[sestamibi]

Regarding the advice to switch into Rads or Anesthesia, my gut feeling is those are the fields that are going to see the deepest cuts, as they are vastly overpaid for what they do now. I dont think the ROAD lifestyles, outside of maybe optho (which has seen the majority of its cuts) and derm (which is just a small niche field) are going to be maintained much longer.

No wonder derm and ophtho are so popular among med students