Discussion: career evaluation and the decision process for plastic surgery graduates.

I would offer an experiential perspective garnered from time spent in three different careers: a pure (however defined) academic position; a hybrid career within an academic group but a group conducted as a private practice corporation; and, finally, a current situation of half-time academic and halftime private practice. The article by Drs. Davison and Clemens has been distilled from a lecture series at their home institution, Georgetown University. The central tenet or hypothesis, if you will, is that one of the most important, if not the most significant, of the professional decisions of a plastic surgery resident is the career and job choice on graduation from one’s residency. Yet, to continue with iteration of the assumed underlying hypothesis, turnover in jobs and career choices in the early years of practice is high. The authors cite national statistics not for plastic surgery, but for physicians in general, and those numbers for plastic surgery may not be available, but personal observations would indicate that the premise is correct. The second element of that hypothesis, at least by implication, is that plastic surgery residents are ill-informed about the necessary prerequisites to arrive at the correct decision about career/job choice. This well-written exposition will address that deficiency quite well. Some points deserve emphasis. Position searches require substantial forward planning to a degree, in my opinion, not fully appreciated by many if not most residents. Besides the necessary time to locate and select (mutually) a position, a subsequent hiatus is also necessary to become credentialed, by hospitals, outpatient surgery centers, and insurance panels. In most instances, each facility or institution has its own credentialing requirements and process and, for reasons that I have not been able to divine, will contact and communicate with the medical school, residencies, and fellowships (if any), all of whom may be slow to respond. Licensure has similar requirements but, in addition, the state medical licensure board may meet infrequently, even quarterly. A hiatus of 3 or 4 months or longer is common and, by definition, occurs after contractual agreement (if not solo practice) between resident and employer/group. The authors list the two reasons why a practitioner may elect departure from a group practice in primary care. One is a poor cultural fit, and the other is compensation. What is a “poor cultural fit” with an established practice in plastic surgery? As outlined by the authors, these two reasons, fit and compensation, are intertwined. Thus, potential questions to be asked by the prospective hire (beyond what he or she will be paid) are: What is the underlying thrust of the practice, not always evident, toward plastic surgery? Is the emphasis predominately one of cosmetic surgery? If so, established referral patterns may dictate bypass of the group for reconstructive problems that signal in turn a longer duration to establish a practice. How is overhead allocated? Practice expenses are fixed (e.g., rent) or variable (e.g., salaries or supplies). If a disproportionate amount of overhead is assigned to the fixed category, including salaries, and these costs are divided equally among the partners, the high earners are rewarded (percentagewise) and the low earners are punished. Are the variable costs, also termed resource-based, divided on the basis of billings or collections? This factor and the one just described may be among the more common sources of misunderstanding and disagreement between a new signee and the group. Variable cost allocation on the basis of billings, which is one estimation of individual practitioner consumption of resources, may be inequitable, even highly inequitable, if a wide disparity exists in collection rates. For example, a senior partner with a mostly cosmetic practice will have a high ( 90 percent) collection rate; in contrast, the young reconstructive surgeon will have perhaps a 40 percent collection rate. Although total billings may be a more accurate reflection of the use of resources, overhead is paid from collections, and the young practitioner is penalized.