Career satisfaction and flexibility in PRS

[a2014]

I'm an M3 trying to figure out exactly what I want to do with my life. I spent some time on the PRS service here and really enjoyed the service and the time in the OR. I'm really leaning towards PRS, but I have a few doubts and a couple of questions before I really commit to that path, and some questions that I feel a bit uncomfortable asking our faculty in person. I'd greatly appreciate any insight that those of you a little further down the path can offer.

1. On surveys of physicians, plastic surgery consistently is one of the worst ranked in terms of career satisfaction, usually worse so than general surgery. I know there are inherent flaws in the methodology used in most of these, but what do you think contributes most to this poor satisfaction?

2. After residency, how flexible is the field in terms of where I live and what my work hours are? In terms of numbers, PRS is one of the smallest medical specialties, which would seem to make it more limited as far as where I am ultimately able to practice. How limited is it? In terms of lifestyle, how controllable is it at the attending level? I know this tends to be frowned upon in medicine, but I realize that at some point in my life I may not want to work 80 hour weeks, and may want to work closer to 40-50 hours/wk. Is this possible?

3. How do you think health care reform is going to affect PRS compared to other specialties?

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[Phloston]

(Just for the record, I'm not a resident/surgeon; I'm mid-way through an MD/PhD in tissue engineering and am also going into PRS)

1. On surveys of physicians, plastic surgery consistently is one of the worst ranked in terms of career satisfaction, usually worse so than general surgery. I know there are inherent flaws in the methodology used in most of these, but what do you think contributes most to this poor satisfaction?

Not enough ardor. My belief is that if you're truly impassioned by your work, then you'll love it, regardless of the natural oscillations.

It's not like hours are haphazard either. I wouldn't think family- or vacation-time would be an issue.

But nevertheless I'd be happy to hear a surgeon's perspective on this.

2. After residency, how flexible is the field in terms of where I live and what my work hours are? In terms of numbers, PRS is one of the smallest medical specialties, which would seem to make it more limited as far as where I am ultimately able to practice. How limited is it? In terms of lifestyle, how controllable is it at the attending level? I know this tends to be frowned upon in medicine, but I realize that at some point in my life I may not want to work 80 hour weeks, and may want to work closer to 40-50 hours/wk. Is this possible?

Quite a few surgeons are in private practice, so I'd think the flexibility is solid. You may even be travelling internationally for your conferences, etc. I think it really just comes down to what you create for yourself. We're all in control of our own lives.

3. How do you think health care reform is going to affect PRS compared to other specialties?

I would think less substantially on a relative scale based on the increasing demand for elective procedures.

The reconstructive side (if insurance is involved) would likely fall in concord with the other specialties.

 

[Valadi]

M4 here just finished with the trail.

1. On surveys of physicians, plastic surgery consistently is one of the worst ranked in terms of career satisfaction, usually worse so than general surgery. I know there are inherent flaws in the methodology used in most of these, but what do you think contributes most to this poor satisfaction?

Medscape Physician LifeStyle Report 2012
http://www.medscape.com/features/slideshow/lifestyle/2012/public

Medscape Physician Compensation Report 2012
http://www.medscape.com/features/slideshow/compensation/2012/public

If you read both what you see is that in terms of lifestyle happiness plastic surgeons rate about average. Nevertheless, they are very disappointed with their compensation. As the attendings on this board have noted previously, reimbursement is down for all specialties but PRS is also being hit. Plastic surgeons were the most upset about declining compensation - and felt the most unjustly reimbursed - compared to other specialties in the Compensation Report.

Anecdotally, from conversations with plastic surgeons (academic and private practice), this seems to make good sense to me. Many have stated something to the effect of, "this job is great, but compensation is not what is used to be." Hence I think that is where the high dissatisfaction comes from in these surveys. (Interestingly, plastic surgeons were also least likely to report feeling that the term "rich" applied to them).

2. After residency, how flexible is the field in terms of where I live and what my work hours are? In terms of numbers, PRS is one of the smallest medical specialties, which would seem to make it more limited as far as where I am ultimately able to practice. How limited is it? In terms of lifestyle, how controllable is it at the attending level? I know this tends to be frowned upon in medicine, but I realize that at some point in my life I may not want to work 80 hour weeks, and may want to work closer to 40-50 hours/wk. Is this possible?

This depends largely on what type of practice you will have and where. A purely elective group practice in the midwest will be a whole lot different than an hand practice in a busy metropolitan area. I've seen established guys work about 40 hours a week with a community plastic surgery practice, and others working over 90 in a busy academic practice (including research time). This will largely be up to you and the ensuing changes in healthcare...

3. How do you think health care reform is going to affect PRS compared to other specialties?

I'm going to defer this question to senior members so that I don't wind up leading you down the wrong path with misinformation!

 

[MPMD]

For what it's worth:

http://www.ncbi.nlm.nih.gov/pubmed/20375767

Only 4% of 505 respondents (20 of 500) regretted their decision to do plastics. Interestingly, the cosmetics guys were by far the most satisfied, followed by mixed, followed by recon only. Interesting only because I think recon cases would be more rewarding (though I guess 14 hour free flaps billed far below cost eventually get old).

 

[igap]

To the question about the future of prs reimbursement.... Anything that you do that is reimbursed with insurance or Medicare will continue to have downward pressure price. Between inflation, the intense interest in cutting the deficit, and the perception that surgeons are overpaid, I can't imagine that reimbursement will ever go up. I think a lot more guys will have to go the out of network route, as this will allow for a reconstructive practice with much higher reimbursement.

To give you an idea about how Medicare reimbursement works, consider that a unilateral DIEP is assigned 40 RVUs. At the Medicare conversion rate of roughly 30 dollars, that's 1200 dollars. No one in their right mind in private practice will do this. He/she would go out of business asap.

Read up on "carve outs", "out of network", and "contribution margin".

 

[droliver]

I think a lot more guys will have to go the out of network route, as this will allow for a reconstructive practice with much higher reimbursement.

Read up on "carve outs", "out of network", and "contribution margin".

Actually, quite the opposite is happening. The ability to charge and balance bill for super high OON fees has been clipped by carriers who mostly now index "usual and customary" fees to some low multiple of medicare and have lateraled huge out of pocket expenses to the patients. Quite simply, patients are refusing these rates en mass and choosing to stay in network and if you want to do any reconstructive surgery you will have to participate in most markets. The days of the $20K DIEP flaps some guys used to do is gone.

 

[Moravian]

Actually, quite the opposite is happening.

Agreed. What's been happening in my area is that hospitals and physicians have been aligning in greater numbers in accordance with criteria for a model of clinical integration. This allows for group bargaining with the carriers to achieve better reimbursements but the numbers are not anywhere near the OON payments. The docs on the outside of this clinical integration are going to be locked out of the contracts and, unless they are making a living doing fee for service, they are going to be in trouble.

 

[igap]

Actually, quite the opposite is happening. The ability to charge and balance bill for super high OON fees has been clipped by carriers who mostly now index "usual and customary" fees to some low multiple of medicare and have lateraled huge out of pocket expenses to the patients. Quite simply, patients are refusing these rates en mass and choosing to stay in network and if you want to do any reconstructive surgery you will have to participate in most markets. The days of the $20K DIEP flaps some guys used to do is gone.

Actually the days of $20K DIEP flaps are defintiely not gone. But that's not really what I was referring to when I mentioned OON. I was thinking of some guys I know who take a lot of ED call and bill OON rates. These guys live in affluent areas and so this works out well financially for them. Then again, it is a difficult lifestyle.

I completely agree though that carriers have moved to cut off the OON spigot for elective reconstructive procedures. I recently read that a carrier in my area is now going to pay only Medicare rates for outpatient ASC cases. That single move has shifted a huge financial burden on to their policy holders. Should be an interesting battle for ASCs doing anything but cosmetics.

 

[igap]

Agreed. What's been happening in my area is that hospitals and physicians have been aligning in greater numbers in accordance with criteria for a model of clinical integration. This allows for group bargaining with the carriers to achieve better reimbursements but the numbers are not anywhere near the OON payments. The docs on the outside of this clinical integration are going to be locked out of the contracts and, unless they are making a living doing fee for service, they are going to be in trouble.

Going forward, I don't see the private practice model for recon working very well at all. And if your payor mix is heavily weighted toward Medicare, you will struggle financially. That said, there is huge demand for reconstructive plastic surgeons, and there are and will continue to be new opportunities for plastic surgeons to align themselves with hospitals, or large groups to gain competitive economic advantages.