Thinking about breast surgery, but is salary actually this low?

[SLUser11]

something that PMR-Pain docs somehow can spell---despite their apparent lack of complex medical decision making........

I would say "despite their apparent lack of attention to details" since Svidrillion's post implied the opposite of how you interpreted it.

As for bookoo or bookoo bucks, I don't think the spelling is necessarily wrong since it's slang, and it's recognized by the internet authority on slang, where one can find many useful terms such as "Bootylicious." Still, it seems like it belongs more in an early 90's surfer movie than a student doctor forum...I could see Keanu saying it right after ripping up a gnarly wave.

I love arguing semantics, btw...

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[VisionaryTics]

I've never been good with French spelling.

I think bookoo/buku was picked up in American slang during the Vietnam War, from the French colonial presence over there.

 

[cpants]

I understand why breast surgeons make less. Technically, breast surgery is not difficult. There aren't really emergencies or call, and the thought process is largely algorithmic. You may argue that breast surgeons don't get compensated for their extensive training, and that is true. But they aren't using that extensive training which was mostly in general surgery. It's hard to argue that someone should get compensated more for subspecialty training in a field that basically any general surgeon can handle without additional training. I think a 3 year residency in breast surgery would be feasible and make a lot of sense.

 

[SLUser11]

I understand why breast surgeons make less. Technically, breast surgery is not difficult. There aren't really emergencies or call, and the thought process is largely algorithmic. You may argue that breast surgeons don't get compensated for their extensive training, and that is true. But they aren't using that extensive training which was mostly in general surgery. It's hard to argue that someone should get compensated more for subspecialty training in a field that basically any general surgeon can handle without additional training. I think a 3 year residency in breast surgery would be feasible and make a lot of sense.

Maybe they can do the lumpectomies, but I'm not sure I agree that any general surgeon can handle a breast specialty practice without additional training, since there's so much office work and perioperative decision making that is learned during fellowship.

Sure, routine breast surgery is not difficult, but I would opine that it's no less difficult than a lot of procedures in other specialties. Also, some people who can do an amazing vascular anastomosis can't do an ALND to save their lives.

I could almost guarantee you that if a study was done to look at outcomes after breast surgery, surgeons in a breast specialty practice would have significantly better results that general surgeons who do breast on the side. Some of this is based on their specialty training, but most of it is based on volume and scope of practice.

 

[cpants]

Maybe they can do the lumpectomies, but I'm not sure I agree that any general surgeon can handle a breast specialty practice without additional training, since there's so much office work and perioperative decision making that is learned during fellowship.

Sure, routine breast surgery is not difficult, but I would opine that it's no less difficult than a lot of procedures in other specialties. Also, some people who can do an amazing vascular anastomosis can't do an ALND to save their lives.

I could almost guarantee you that if a study was done to look at outcomes after breast surgery, surgeons in a breast specialty practice would have significantly better results that general surgeons who do breast on the side. Some of this is based on their specialty training, but most of it is based on volume and scope of practice.

I guess I disagree. Both technically and intellectually, breast surgery is not that demanding. A competent general surgeon can do any breast case. Sure, a vascular guy who hasn't done a mastectomy since residency might struggle, but your average general surgeon does this stuff on at least a semi-regular basis. This isn't the kind of surgery that requires high volume to stay sharp. I honestly don't mean that as an insult to breast surgeons. I just think you can't cherry pick one of the least demanding areas of surgery and expect to be compensated more for subspecializing.

 

[Smurfette]

I guess I disagree. Both technically and intellectually, breast surgery is not that demanding. A competent general surgeon can do any breast case. Sure, a vascular guy who hasn't done a mastectomy since residency might struggle, but your average general surgeon does this stuff on at least a semi-regular basis. This isn't the kind of surgery that requires high volume to stay sharp. I honestly don't mean that as an insult to breast surgeons. I just think you can't cherry pick one of the least demanding areas of surgery and expect to be compensated more for subspecializing.

I do a lot of breast stuff as a female general surgeon. My volume is probably at least 4-5x more than my male partner. While breast surgeries may not be equivalent in complexity to some other procedures I do, there are plenty of quirky scenarios that come up that are not straight forward as far as decision-making. i.e. one SLN with a micromet-->don't need ALND. What if TWO SLNs have micromets found on permanent and not on frozen? Some stuff doesn't fit into NCCN guidelines.

Reimbursement is just different....a breast-only practice is much more office-based than a general surgery (or other subspecialty) practice. I also find that breast patients take more office time...and more visits, etc. which also make it less lucrative compared to other complaints like cholelithiasis, who get scheduled for the OR at the first visit and have a fast post op visit. The insurers pay based on what you do...office stuff doesn't pay as well as OR procedures.

I do agree that I should be paid the same for doing the same work as another surgeon; if I do a lap right hemi, I should get paid the same as a colorectal guy, just like I should be paid the same for a mastectomy as a breast surgeon would. But both the colorectal guy and the breast surgeon will have some skills/knowledge I don't, and those skills should be reimbursed appropriately...this is why I don't do lap APRs, brachytherapy, and other things.

 

[droliver]

I could almost guarantee you that if a study was done to look at outcomes after breast surgery, surgeons in a breast specialty practice would have significantly better results that general surgeons who do breast on the side.

I can guarantee you that such a study would show absolutely no difference as the procedures across the board involved with breast cancer are not highly technically challenging or morbid procedures as compared to some of the procedures where there has been some differences in outcome observed (hepato-biliary, pancreatic, transplant, and some advanced colorectal cases).

 

[SLUser11]

I can guarantee you that such a study would show absolutely no difference as the procedures across the board involved with breast cancer are not highly technically challenging or morbid procedures as compared to some of the procedures where there has been some differences in outcome observed (hepato-biliary, pancreatic, transplant, and some advanced colorectal cases).

I disagree. The morbidity of breast procedures is not zero. The significance of having a breast-focused practice would depend on what end-points you look at. Things like positive margins during lumpectomy (super common), need for reoperation, cosmetic outcomes, stage-specific survival, and wound complications would likely be better for someone who has a larger volume of breast cases.

The perioperative care is also likely different. Looking at when patients received appropriate genetic counseling, or were offered the appropriate sequence of systemic therapy, or the appropriate mode of diagnosis (core needle vs. excisional biopsy), would likely be different.

In the end, it has very little to do with the technical complexity of the case. It has everything to do with volume.

 

[droliver]

As someone who actually considers themselves somewhat of a breast surgery specialist, I could not disagree more.

Involved margin rate is really not a proxy for skill as even someone unskilled can have low rates if they just took large specimens most of the time. Using low involved margin rates also runs head long into your idea of cosmesis, as the best way to get low involved margins is usually to take more aggressive specimens which subsequently produces the worst lumpectomy defects. Further, stage specific survival is more related to the properties of the tumor itself and is more influenced by adjuvant CRT/XRT assuming negative margins are achieved with the resection (which again does not require much specialized skill to achieve). The other issues re. workup, diagnosis, counseling, etc... are pretty much cookbook and are nearly universally delivered in most metro areas. Deviations from what would be considered the most current diagnostic or therapeutic procedures are usually in outlying areas where the ability to do some of the image guided studies may be limited.

The take home message is that it's just not that hard to do breast cancer procedures in a technical sense (and with ALND looking like it's going to be obsolete, it's even getting more so), and that low bar is going to blunt much of a difference ever being able to be demonstrated between different surgeons.

 

[blue2000]

The take home message is that it's just not that hard to do breast cancer procedures in a technical sense (and with ALND looking like it's going to be obsolete, it's even getting more so), and that low bar is going to blunt much of a difference ever being able to be demonstrated between different surgeons.

This is a topic I'm thinking a lot about lately, and apologize for high-jacking the thread, but it seems as good of a time as any --

What are people recommended to their patient's re: ALND? I admit that I was impressed with the JAMA study (JAMA. 2011 Feb 9;305(6):569-75) and am having a hard time pushing for full ALND in T1-T2 patients these days. I tend to lay out the current "state of the art" for my patients, including a full discussion of the morbidity of lymphedema, explain to them that it is a current controversy in breast surgery right now, and see which way they lean. My breast surgery volume isn' t huge, so I haven't seen a T1 or T2 SLN positive patient recently. Does anyone not like this study? Is anyone strongly in favor of abandoning ALND in these patients?

 

[droliver]

Currently, there's still a lot of caveats with the "skip the ALND for SLN positive patients".

The ACOSOG Z0011 (which actually closed early due to poor accrual BTW) conclusion of no benefit either in local, regional, or overall survival for patients undergoing node dissection versus observation for one or two positive lymph nodes (in patients treated with breast conserving therapy and whole breast radiation. It is NOT currently applicable to mastectomy patients.

On the other hand, there are other recent papers (here) which suggest higher regional failure in favorable tumors when omitting ALND for even isolated cells and micromets, which most of already would defer completion dissection. Kind of muddies the water a little on a clear conclusion of when we'll be able to just be ok with a yes/no answer with the nodes and rely on adjuvant therapy to treat residual disease..

 

[SLUser11]

The other issues re. workup, diagnosis, counseling, etc... are pretty much cookbook and are nearly universally delivered in most metro areas. Deviations from what would be considered the most current diagnostic or therapeutic procedures are usually in outlying areas where the ability to do some of the image guided studies may be limited.

Do you think that most breast care is delivered in these metro areas you've described? Do you really think that most general surgeons are familiar with this "cookbook" and all the correct steps/sequences for breast care? This cookbook has changed a lot in the last 10 years...do you think practicing general surgeons have kept up with these changes?

Do you really think some of the newer, more cosmetically appealing options (e.g. skin-sparing, nipple-sparing mastectomy) are being universally practiced by part-time breast surgeons? Do you think, as a plastic surgeon, that patients are being universally offered appropriate reconstruction options in an appropriate time frame?

I doubt we'll come to a resolution on this issue. I agree with you that breast surgery is not technically difficult, but I still believe the breast specialist offers better care.

 

[flyingsutures]

http://www.cms.hhs.gov/AcuteInpatientPPS/Downloads/AMGA_08_data.pdf

Well, sorry about interrupting the discussion here, but it seems to have died out anyway. I'm going to try to take us back to the original topic of this thread. See the quote above.

Here we are in 2012, and this is the most recent salary information I can find? Can anybody give me some info about salary information for breast surgeons? I'm not expecting to get rich, but it would be nice to pay off some med school debt...

 

[Winged Scapula]

The range of salary and/or income in breast surgery is quite variable. The income surveys are often skewed and may not represent the true picture for many reasons.

I can tell you that I make significantly more than the survey link you have provided above. However I have a high-volume practice, do my own in office and stereotactic biopsies, do my own needle and radioactive seed localizations, and I'm very aggressive about doing so. In addition I upcode for prolonged consultations because I have a heavy oncologic practice with extended office appointment times.

Therefore it is a fallacy that you can't make good money in breast surgery but to do so, you have to do what I do. I think you will find that $200,000 is not an unusual salary even in 2012. Many practices and hospitals underpay breast surgeons because they figure we don't take call and we don't bring in higher-paying surgeries; some of the hospital employed breast surgeons don't do their own biopsies and don't therefore maximize the payment flow through. The typical reimbursement for breast surgery in the operating room is low. I make more money in the office doing biopsies and placing Brachytherapy catheters that I do in the operating room.

What they neglect to include in the calculations is in addition to the above, we also make high-paying referrals to medical and radiation oncology.

So long answer to your short question is that breast surgery is not as high-paying as some of the other surgical specialties and that 200,000 or less is not unheard of in 2012. But there are ways to push that number mostly as a partner in private practice or by running a breast Center with considerable administrative time.

 

[45408]

I can tell you that I make significantly more than the survey link you have provided above. However I have a high-volume practice, do my own in office and stereotactic biopsies, do my own needle and radioactive seed localizations, and I'm very aggressive about doing so. In addition I up Cody for prolonged consultations because I have a heavy oncologic practice with extended office appointment times.

Do you get to bill a facility fee as well when you do these sorts of things in your office?

 

[flyingsutures]

Winged Scapula,
I almost hate to ask a question like this, but lately it's lurking in the back of my mind, so here goes: As a very busy surgeon, are you able to pull off a healthy balance between family and your practice? As a 5th year GS resident, I'm beginning to wonder...
I love my choice of career, and I've never looked back. That being said, I also want to be a successful mother and wife. Tall order?
flyingsutures

 

[flyingsutures]

But there are ways to push that number mostly as a partner in private practice or by running a breast Center with considerable administrative time.

Winged Scapula,
A partner in private practice or running a breast center. I guess that's after one gets some experience under his belt? Or maybe not?

Do you have any advice for a fellowshipped (if that's a word) surgical breast oncologist that is just starting out? What kind of job would be best to start out with to get the experience necessary to be successful? (Okay, I've got to get a fellowship first, I know!) Surely I can do that...
flyingsutures

 

[dpmd]

What they neglect to include in the calculations is in addition to the above, we also make high-paying referrals to medical and radiation oncology.

You get paid to refer patients to the oncologists? Wouldn't that be a kickback?

 

[LucidSplash]

You get paid to refer patients to the oncologists? Wouldn't that be a kickback?

I'm fairly certain she meant the hospital gets revenue based on oncology/rad onc treatment after the consults that breast surgeons make to oncology/rad onc and they fail to take this into their calculations when deciding what a breast surgeon is "worth."

 

[Winged Scapula]

Do you get to bill a facility fee as well when you do these sorts of things in your office?

In a sense. There is not a separate facility fee - but when I perform a biopsy in my office (a building which we own), the reimbursement includes a facility and technical fee which is higher than I would receive if I were to do the same biopsy at the hospital in the radiology suite/breast center (where I would only get the technical fee).

This is why I was not interested in running a clinic at the hospital down the street and doing biopsies there when I could do it in the comfort of my own office and make more money.

 

[Winged Scapula]

You get paid to refer patients to the oncologists? Wouldn't that be a kickback?

I'm fairly certain she meant the hospital gets revenue based on oncology/rad onc treatment after the consults that breast surgeons make to oncology/rad onc and they fail to take this into their calculations when deciding what a breast surgeon is "worth."

The above is exactly what I meant.

I receive no direct payments for referrals to other specialists, nor would a hospital employee.It would be a Starck Law violation.

However, medical oncology and radiation oncology services bring in a lot of money; the breast surgeon is the largest source of referral to those specialists for patients with breast cancer (i.e., we do the referring rather than the PCPs), so the hospital benefits from those referrals if those specialists are hospital employees or bring patients to the hospital for treatment (i.e., rads studies, chemotherapy, radiation therapy etc). As LucidSplash notes (and what I was attempting to say) is that hospitals neglect to include that (or willfully leave it out) when determining how much a breast surgeon on staff is "worth".

 

[Winged Scapula]

Winged Scapula,
I almost hate to ask a question like this, but lately it's lurking in the back of my mind, so here goes: As a very busy surgeon, are you able to pull off a healthy balance between family and your practice? As a 5th year GS resident, I'm beginning to wonder...
I love my choice of career, and I've never looked back. That being said, I also want to be a successful mother and wife. Tall order?
flyingsutures

I am not the person to ask.

I am single by choice/chance and childless by choice. I have a very active social/dating life but there are times when the job comes first (not home before 830 for the last two weeks-its been crazy in the ORs).

But my two cents:Most of my breast and plastic surgeon female friends are married, and many are married to men who have less education, less demanding and more flexible jobs. Even the ones married to men with white collar jobs often have less time constraints allowing them to do a large part of the childcare. Their husbands are the ones who pick the kids up from school, take them to piano and soccer lessons, etc. But these women *are* involved in their kids lives; that means that they take charts to weekend sporting events or stay up very late at night after the kids are in bed, doing charting. They have little time for self-care.

There is a reason why my pedicures are always shiny and I have time to get facials and workout with a trainer. Its not that you can't do that as a wife and mother and surgeon; the time challenges are just that much more difficult.

 

[Winged Scapula]

Winged Scapula,
A partner in private practice or running a breast center. I guess that's after one gets some experience under his belt? Or maybe not?

Eh, I interviewed for jobs running breast centers right out of fellowships. I wouldn't have known a damn thing about what to do, but they interviewed me and I was even offered a few, so it must have not been that big of a deal. I got the feeling that the fellowship label was a marketing tool for them and that I could learn on the job.

I became partner after 2 years of a salary guarantee. I wouldn't take any job that didn't have that as an option.

Do you have any advice for a fellowshipped (if that's a word) surgical breast oncologist that is just starting out? What kind of job would be best to start out with to get the experience necessary to be successful? (Okay, I've got to get a fellowship first, I know!) Surely I can do that...
flyingsutures

Some quick things.

If you know where you want to be after fellowship then your training should help you achieve that. It does no good to train at "BMS" Top Tier fellowship if your goal is a private community practice because you will not likely be trained to do your own biopsies, needle localizations, brachytherapy catheters, etc. So pick the type of training environment that leads you where you want to go.

You will need a mentor. I interviewed for lots of jobs where I would have been the only breast surgeon on staff and there was some/considerable animosity from the general surgeons on staff, who saw me as a threat. They would not have mentored me and I could have floundered. You cannot be successful without help and you cannot come in "guns a blazing" a expect that everyone will love you (at least not at first).

Most people don't stay in their first job; given that I'm more than 5 years out now, most of my academic practice friends have moved on to other programs and several of the private practice ones have found other jobs. I was a bit jealous of one friend who took this "great job" with a signing bonus, generous moving allowance, etc. I had to ask for the moving allowance, and no signing bonus was available. Her salary guarantee was higher than mine. But less than a 18 months in she was referring to her employers (a large group of breast surgeons and breast radiologists) as "those bitches", she was not offered partnership and she left when she was told she wouldn't be made partner *2 weeks* before her wedding. Like she didn't have enough stress. Drama is not required but it can happen. I got lucky and really like my partner and did from the first time I met her. So, you have to assess the *situation* and the *people* as IMHO those are more important than the financials (but you have to be smart about those).

Use whatever resources you can to find a job: adverts, head hunters, cold calling, friends, etc. There were some seminars when I was a fellow run by Cam and Mike Teems which were very useful. Network with your fellowship colleagues at other programs; I cannot tell you how many jobs are out there which are just word of mouth and never advertised. From my year, we all kept in touch and let each other know about job opportunities, people to stay away from (one guy in Vegas interviewed a few of us, until we caught on to him and his charade), etc.

 

[maxheadroom]

You will need a mentor. I interviewed for lots of jobs where I would have been the only breast surgeon on staff and there was some/considerable animosity from the general surgeons on staff, who saw me as a threat. They would not have mentored me and I could have floundered. You cannot be successful without help and you cannot come in "guns a blazing" a expect that everyone will love you (at least not at first).

Most people don't stay in their first job; given that I'm more than 5 years out now, most of my academic practice friends have moved on to other programs and several of the private practice ones have found other jobs. I was a bit jealous of one friend who took this "great job" with a signing bonus, generous moving allowance, etc. I had to ask for the moving allowance, and no signing bonus was available. Her salary guarantee was higher than mine. But less than a 18 months in she was referring to her employers (a large group of breast surgeons and breast radiologists) as "those bitches", she was not offered partnership and she left when she was told she wouldn't be made partner *2 weeks* before her wedding. Like she didn't have enough stress. Drama is not required but it can happen. I got lucky and really like my partner and did from the first time I met her. So, you have to assess the *situation* and the *people* as IMHO those are more important than the financials (but you have to be smart about those).

Use whatever resources you can to find a job: adverts, head hunters, cold calling, friends, etc. There were some seminars when I was a fellow run by Cam and Mike Teems which were very useful. Network with your fellowship colleagues at other programs; I cannot tell you how many jobs are out there which are just word of mouth and never advertised. From my year, we all kept in touch and let each other know about job opportunities, people to stay away from (one guy in Vegas interviewed a few of us, until we caught on to him and his charade), etc.

Listen, you Padawan-learners. Dr WS gives excellent advice here. Big signing bonuses/high salary guarantees are usually masking something really $hitty about a job. Having a senior partner who can help you is unbelievably important. And there are more important things than money.

 

[flyingsutures]

Thanks for the great advice, Winged Scapula and Maxheadroom.

 

[dpmd]

The above is exactly what I meant.

I receive no direct payments for referrals to other specialists, nor would a hospital employee.It would be a Starck Law violation.

However, medical oncology and radiation oncology services bring in a lot of money; the breast surgeon is the largest source of referral to those specialists for patients with breast cancer (i.e., we do the referring rather than the PCPs), so the hospital benefits from those referrals if those specialists are hospital employees or bring patients to the hospital for treatment (i.e., rads studies, chemotherapy, radiation therapy etc). As LucidSplash notes (and what I was attempting to say) is that hospitals neglect to include that (or willfully leave it out) when determining how much a breast surgeon on staff is "worth".

I was confused because I thought it sounded shady, and you don't seem like a shady person. Not that you cleared it up I feel sort of dumb for not figuring out what you meant at first

 

[Winged Scapula]

I was confused because I thought it sounded shady, and you don't seem like a shady person. Not that you cleared it up I feel sort of dumb for not figuring out what you meant at first

No worries...it can be easy to misinterpret things on line.

I don't think I'm "shady" either but there are plenty of SDNers whom have met me IRL who could better comment on that.

(last comment only so I could use cool Ninja emoticon...LOL)

 

[Fah-Q]

Big signing bonuses/high salary guarantees are usually masking something really $hitty about a job.

Listen closely to the above. There are no free lunches. Nobody is going to hand you loads of money just because you are super awesome. You either earn your money or someone will take it back from you in some form or fashion (shifting lower paying patients to your schedule, increasing your share of overhead, more call, less vacation, denying partnership, etc).