Question about private practice scope

[trogdor41]

To make a long story short, I'm on the fence about doing a facial plastics fellowship vs doing general ENT. I am interested in Moh's reconstruction, otoplasty, etc. in addition to general ENT. I understand that the scope of private practice is likely highly variable, but is anyone aware of non-fellowship trained private guys doing paramedian forehead flaps and simple Moh's reconstructions out in the community? Or are these procedures strictly the territory of FPRS trained otos?

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[lildave2586]

To make a long story short, I'm on the fence about doing a facial plastics fellowship vs doing general ENT. I am interested in Moh's reconstruction, otoplasty, etc. in addition to general ENT. I understand that the scope of private practice is likely highly variable, but is anyone aware of non-fellowship trained private guys doing paramedian forehead flaps and simple Moh's reconstructions out in the community? Or are these procedures strictly the territory of FPRS trained otos?

Of course, there are plenty of general ENTs doing those procedures. The only thing is you have to go out and get them. There is nothing particularly challenging about a PMFF or a nasolabial flap. If you have had the training in your residency, then you can do it. These things are generally limited by what the focus of your training has been. I did a large volume of PMFF in my training and have no issues doing them now. With that being said, you are going to have to make your own referral base. You will have more luck if you go into a smaller community. If you try to build a reconstruction practice in a big city, you will be in for a challenge.

I joined a small practice in a small community of about 75,000 with a service area of about 450,000. I decided that I wanted to start a CI program and had the backing of my hospital (I didnt do an otology fellowship). A little over one year in and we've done about 35 implants. Since I'm in a small community I'm the only game in town and actually starting to service the entire region. I've had patients come from over 200 miles away for CI surgery. I never could have done this in a city with an academic center or a fellowship trained otologist.

So if you want to live in some fancy place and do facial recon, you better get a fellowship. If you are content in middle America, you can do anything you want.

 

[HighPriest]

To make a long story short, I'm on the fence about doing a facial plastics fellowship vs doing general ENT. I am interested in Moh's reconstruction, otoplasty, etc. in addition to general ENT. I understand that the scope of private practice is likely highly variable, but is anyone aware of non-fellowship trained private guys doing paramedian forehead flaps and simple Moh's reconstructions out in the community? Or are these procedures strictly the territory of FPRS trained otos?

I do these things. I didn’t do a fellowship.

 

[DrBodacious]

Hi. I am general and I do nasal reconstruction, including PMFF, septal hinge flaps for full thickness defects, etc. There is a Mohs surgeon that sends me the complex stuff he can't do in his office. I also do functional and cosmetic rhinoplasty. I also do a variety of other more complex procedures, which in my mind would be (for a generalist) cholesteatoma, messy revision tympanoplasties including lateral graft, facial recesses, terrible sinus cases including frontal sinus drill outs, neck dissections, thyroids, parotids, etc.

You don't need a fellowship for anything you covered in residency. I am honest with myself with my results, which are as good as anyone, and I haven't really excluded much unless it obviously requires an academic team to manage.

The big questions is where you are going to practice? And where would your referrals come from? Fellowships are useful marketing tools, so if you have your heart set on doing facial plastics in an area with competition for referrals, it would help. On the other hand, if you a fellowship trained person, and you really do general and half-ass your sub-specialty, you will probably not get as many referrals from other nearby ENT doctors. i.e. having a fellowship can be somewhat threatening and potentially work against you. Ideally, you are going somewhere where there is a great need for your services.

 

[Wordead]

Hi. I am general and I do nasal reconstruction, including PMFF, septal hinge flaps for full thickness defects, etc. There is a Mohs surgeon that sends me the complex stuff he can't do in his office. I also do functional and cosmetic rhinoplasty. I also do a variety of other more complex procedures, which in my mind would be (for a generalist) cholesteatoma, messy revision tympanoplasties including lateral graft, facial recesses, terrible sinus cases including frontal sinus drill outs, neck dissections, thyroids, parotids, etc.

You don't need a fellowship for anything you covered in residency. I am honest with myself with my results, which are as good as anyone, and I haven't really excluded much unless it obviously requires an academic team to manage.

The big questions is where you are going to practice? And where would your referrals come from? Fellowships are useful marketing tools, so if you have your heart set on doing facial plastics in an area with competition for referrals, it would help. On the other hand, if you a fellowship trained person, and you really do general and half-ass your sub-specialty, you will probably not get as many referrals from other nearby ENT doctors. i.e. having a fellowship can be somewhat threatening and potentially work against you. Ideally, you are going somewhere where there is a great need for your services.

Did you do a lot of local recon in residency or was there another way you got to the point of feeling comfortable with those?

 

[DrBodacious]

Did you do a lot of local recon in residency or was there another way you got to the point of feeling comfortable with those?

Looking at my case log, I coded 28 procedures for local flaps, 19 rhinoplasties, 4 PMMFs. We had a strong public hospital system, where I was able to take the reigns on a couple of these PMMFs, which happened to include internal lining reconstruction, including all the preop planning, intraop decisions, and seeing them in follow up in the clinic. Attendings were there at their whim or at your request.

We had private hospital rotations, also, where you are performing the will of the attending, so it is nice to have a mix to build confidence and know you are doing it correctly.

So, whether it is your first year(s) out in practice, or during your residency, you have to develop your self awareness and confidence with any procedure. There are inevitably unpredictable situations that come up, and part of it is gaining confidence that you can perform well in those situations to be safe and get the desired outcome.

I also believe that as a generalist, the various fields of ENT have cross-training benefits. The more types of things that are thrown at you, the more suited you are to deal with random problems. A few weeks ago, I used an ear drill to drill off the outer cortex of exposed bone to get to cancellous bone and apply a STSG for coverage (Moh's defect). Drilling mastoids, placing BAHAs, and doing bicoronal approaches for trauma all played in to me having no issue doing that, although I hadn't had that case come up since residency, and maybe once back then. Sure, I am not going to experience the same depth as a busy sub-specialist, but I'd argue the added breadth makes up for it and I can select my own cases rather than rely on referrals from other ENTs.

Ultimately, you are the best judge or yourself and your current abilities and you should decide on your own future goals and develop plans to get there. Once you assess what your needs are, you can do a fellowship for one of three reasons: 1) to build your skill and confidence, 2) the marketing benefits, 3) if you are going in to academia. If you don't need any of those things, a fellowship may not be necessary.

So, in other words "getting to the point of feeling comfortable with" {insert case} has always been a goal for me, and I have developed my practice incorporating that goal.

 

[rhy1704]

I have noticed that in other fields, the percentage of people specializing and doing fellowships has increased. Basically everyone in Orthopedics does a fellowship.. More and more general surgeons are also doing a fellowships - trauma, CT, colorectal, etc.

I know people have commented on doing a fellowship if you are going into academia/marketing benefits, larger city practice... However, does anyone have reason to believe that ENT will follow a similar path of other fields where its almost required to do a fellowship?

I wasn't really planning on doing a fellowship. I am thinking of doing general and practicing in a smaller city.

 

[TonsilPlucker]

I have noticed that in other fields, the percentage of people specializing and doing fellowships has increased. Basically everyone in Orthopedics does a fellowship.. More and more general surgeons are also doing a fellowships - trauma, CT, colorectal, etc.

I know people have commented on doing a fellowship if you are going into academia/marketing benefits, larger city practice... However, does anyone have reason to believe that ENT will follow a similar path of other fields where its almost required to do a fellowship?

I wasn't really planning on doing a fellowship. I am thinking of doing general and practicing in a smaller city.

If you have an idea of the breadth of practice that you want to do, and you feel confident that you have the skill set to do it, a fellowship is in no way necessary if you are practicing in a mid to small size city. If you're lucky, a fellowship really isn't necessary in a large city either.

That being said, medicine is changing, and ENT along with it. As techniques evolve, subspecialties expand in their own breadth, I think you will see more and more people in ENT subspecialize, even if the intent is the added name/fellowship on the diploma while practicing mostly general ENT.

 

[HighPriest]

Currently, you don't need a fellowship. ENT is still fairly significantly under-served. There are almost certainly metro areas in which "general" ENT is quarantined to the land of tubes and tonsils, but generally speaking that's not the case. We're still fairly roundly misunderstood by most primary care providers (they have no idea what we do) and so asking them to decide which sub-subspecialist to refer patients to is a tall order. what that means is that as a general ENT, by and large, patients are still coming to you first, and you're sending them to the Head and Neck guy or the facial plastics guy, etc. So you keep what you want, and you send the rest on. If you're in a practice with fellowship trained guys, that's a different story. Sometimes it's a great story, because when I had a neuro-otology partner I sent him 100% of my dizzy patients, and it was like seeing the sunrise for the first time.

Will that change? Will you eventually need a fellowship? Maybe. But with a well-rounded residency I think you can come out feeling fairly comfortable doing most of the breadth of ENT without a fellowship. The only oncology I don't feel comfortable doing is TORs and stuff that will require a free flap (and of course I'm certified to do neither). I feel comfortable doing almost any facial plastic stuff, but I certainly choose not to do a lot of it.

 

[rhy1704]

f you have an idea of the breadth of practice that you want to do, and you feel confident that you have the skill set to do it, a fellowship is in no way necessary if you are practicing in a mid to small size city. If you're lucky, a fellowship really isn't necessary in a large city either.

When people talk about large city vs small city, what size are we talking about?

I've been in the PSLF program while in residency and I have about $180k in educational loans. I've thought about going for the PSLF and joining a non-profit hospital group upon graduation but I think in the long run, I would be happier in the private practice setting. However, 1) those jobs are becoming more scarce to come by and 2) PSLF is not an option at that point leaving a large loan bill... Any opinions or recommendations? I'm single and flexible where I end up ultimately practicing medicine.

 

[HighPriest]

Size of the city is less important than the number of ENT docs. If there's a relative shortage of ENT, then you will probably be able to do whatever you want. If the city is flush, then you may be relegated to basic stuff. It's case-by-base.

There isn't a huge shortage of ENT private practice. This also depends upon where you are. If you're looking to live in an area with a ton of state/welfare patients, then it isn't financially beneficial to stay private. But if you live somewhere with a lot of tech (for example) or even a large blue collar industry where the company still provides insurance, you can do very well in private practice. $180k in student loans, in both of these situations, is very manageable. You will need to work hard, and you will need to be productive, and you will need to live on a budget. If you can't, or aren't interested, in doing any of those things then PSLF is very reasonable.

 

[rhy1704]

Size of the city is less important than the number of ENT docs. If there's a relative shortage of ENT, then you will probably be able to do whatever you want. If the city is flush, then you may be relegated to basic stuff. It's case-by-base.

There isn't a huge shortage of ENT private practice. This also depends upon where you are. If you're looking to live in an area with a ton of state/welfare patients, then it isn't financially beneficial to stay private. But if you live somewhere with a lot of tech (for example) or even a large blue collar industry where the company still provides insurance, you can do very well in private practice. $180k in student loans, in both of these situations, is very manageable. You will need to work hard, and you will need to be productive, and you will need to live on a budget. If you can't, or aren't interested, in doing any of those things then PSLF is very reasonable.

I'm currently living on a pretty good budget. I've been maxing out my 457b from the hospital I work at and a Roth IRA each year and plan to continue to do so.

 

[TonsilPlucker]

I wouldn't worry about your loans. You'll be fine in either situation as long as you're not blowing money early on. Once they're paid off, you can join the Maserati and Porsche talk at the big boy table.

 

[rhy1704]

My plan is to continue to "live like a resident" for several years after residency. I want to save a bunch of money and either pay off my loans or put it to the side if I may be going for PSLF just in case that program collapses. I also want to save a large change of money to get my big kid life started - i.e a house.... hahah, I don't think I am cool enough to join the big boy table.

 

[HighPriest]

Yeah, listen, as someone who traded 9 years of their life and a chunk of their soul to avoid loan repayments: hindsight tells me I should have worried about the loans less.

 

[Graywolf]

Yeah, listen, as someone who traded 9 years of their life and a chunk of their soul to avoid loan repayments: hindsight tells me I should have worried about the loans less.

You mean you if you could do it over again you would take the loans from Uncle Sam and just pay them off the good old fashioned way?

 

[HighPriest]

I would find some way to do it that didn't involve the Army.

But, then again, that's hindsight talking and who knows: if I had gone the other way I might be saying that I wish I'd done the Army. But I don't think so. If you end up in ENT, and if you end up making an average ENT wage, you can pay off your loans with sound financial decisions.

 

[OtoHNS]

If you continue to live the lifestyle of a resident, you can pay off $180k in debt in 1 year if you are willing to work in a non-saturated area.

 

[Graywolf]

If you continue to live the lifestyle of a resident, you can pay off $180k in debt in 1 year if you are willing to work in a non-saturated area.

I am willing to live like a resident -- but my wife is likely not. The age old dilemma. She's not the materialistic type, but the "I've been dealing with this for 5-10 years...when will things get [financially and lifestyle] better?" type of mentality.

 

[rhy1704]

If you continue to live the lifestyle of a resident, you can pay off $180k in debt in 1 year if you are willing to work in a non-saturated area.

That's my plan. Which is another reason why I don't think I want to pursue a fellowship. Another year of training = another year of lost income.

 

[Ethmoid911]

I have noticed that in other fields, the percentage of people specializing and doing fellowships has increased. Basically everyone in Orthopedics does a fellowship.. More and more general surgeons are also doing a fellowships - trauma, CT, colorectal, etc.

I know people have commented on doing a fellowship if you are going into academia/marketing benefits, larger city practice... However, does anyone have reason to believe that ENT will follow a similar path of other fields where its almost required to do a fellowship?

I wasn't really planning on doing a fellowship. I am thinking of doing general and practicing in a smaller city.

I write this as i check on a 3.5hr revision revision revision bloody AERD case. I was crying inside during the case but I look back and I love it. And I am proud although I just spent half of my day on this poor patient.

I did a rhinology fellowship (heavy academic one) because I loved the anatomy and wanted to be the terminal guy in the future. I practice general ENT now but do all the complex frontals, polyps, tumors, for my colleagues. It drags down my RVUs but I have no regrets because otherwise, id experience burn out. I love the challenge of providing complex care in private practice. Otherwise, I'd be depressed with thyroids and ear wax. Sorry, I just cannot stand the mental anguish of thyroids and parathyroids. Can I find my way through a thyroid? Yes. Can I still do a quick trach while on call? Yeah, if I have to. But not if I have a choice. Last parotid I did was 4years ago. Not doing that again...boring. but hey, my partner lives for that and won't even touch a complex septoplasty. So, good for us.

So, unless you want to be a big plastics doc in solo.private practice (where fellowship will get you far for , if you are going into private practice , do a fellowship if you enjoy the subspecialty or want to be the group expert. Or if you don't want to be expected to do BAHAs and thyroids.

 

[Ethmoid911]

My plan is to continue to "live like a resident" for several years after residency. I want to save a bunch of money and either pay off my loans or put it to the side if I may be going for PSLF just in case that program collapses. I also want to save a large change of money to get my big kid life started - i.e a house.... hahah, I don't think I am cool enough to join the big boy table.

You can save money but please stop suffering "like a resident". Rent a good space, get a nice car, go on a weekly date night. Maybe get a nice house in 5-7yrs out when you have a good down payment to avoid high interest rate mortgage. But please stop.living like a resident. You've worked hard and will work harder for the next 20yrs. Take a breathe, spend a little, save enough.