'It all came together': The costs and benefits of breaking the practice mold

A plastic surgeon who is coming out of training has the same options ahead of him or her that have almost always been there – venture out to claim your spot in the specialty's landscape and build your own practice, join an academic institution or a hospital.

Still, as the landscape shifts and some private practitioners find it increasingly challenging to compete in the marketplace, both young and veteran surgeons alike are pursuing opportunities and constructs that can provide more options geographically and professionally.

PSN spoke to a handful of doctors working in constructs outside of the norm and got a better understanding of the benefits and challenges of everything from helping with "Botox weekends" in Montego Bay to joining a dermatologist's office as the resident plastic surgeon.

Home and abroad

When an upscale resort in Montego Bay offered to host "Botox weekends" in its on-site hospital in 2002, ASPS member Z. Paul Lorenc, MD, agreed to expand his Manhattan practice and service patients seeking cosmetic treatments during their Caribbean vacations. The response prompted Dr. Lorenc to travel to Montego Bay quarterly to provide injectable treatments and become licensed to practice medicine on the island. He eventually expanded his services in Jamaica to provide liposuction and other cosmetic procedures for a decade.

"It was very common for patients to combine their treatments with vacation," says Dr. Lorenc. "During those weekends, I treated patients with both Botox and Restylane, which was approved in Jamaica while it was not yet approved in the United States. I enjoyed treating patients who otherwise would not have had their needs met, or who wanted to recover in beautiful Montego Bay."

Still, as with many of the multi-city or multinational doctors with whom PSN spoke, time commitments played a factor. Dr. Lorenc stopped practicing in Montego Bay because of the squeeze it put on his schedule; he currently spends most of his time treating patients in Manhattan. Nevertheless, the travel bug returned and he started practicing overseas again three years ago, with occasional travels to Abu Dhabi to perform minor procedures based on patient referrals. The time constraints notwithstanding, Dr. Lorenc says the experience potentiates his practice overall.

That's a common line of thinking for Josef Hadeed, MD, Beverly Hills and Miami, who opened his third practice in Abu Dhabi last year to expand his international presence. Dr. Hadeed worked with the American Surgecenter in Abu Dhabi to obtain a medical license through the local health authority before applying for privileges at an ambulatory surgery center and local hospitals affiliated with the clinic. He travels to his office in Abu Dhabi two to three times per year and spends most of his time providing consultations, surgeries, in-office procedures and follow-up visits.

Dr. Hadeed, who sees up to 40 patients during his three-week visits, quickly discovered that his international patients seek the same cosmetic procedures as his patients in Beverly Hills and Miami – the most common procedures he performs in Abu Dhabi include breast augmentation, tummy tucks and liposuction.

Although Dr. Hadeed concedes that while practicing overseas has its drawbacks – such as time-management challenges, scheduling, marketing and spending time away from his primary office in Beverly Hills – he tells PSN he's in it for the long haul.

"I didn't want to limit myself to just operating locally," he says. "I have an agreement with a plastic surgeon back home and a plastic surgeon in Abu Dhabi to look after my patients when I'm traveling. My biggest piece of advice to surgeons who want to practice abroad is: Have the proper infrastructure in place regarding the physical office space and staffing – and develop relationships with local plastic surgeons in those countries who could look after your patients when you're not there."

The United Arab Emirates appears to have a lot to offer plastic surgeons. After noticing a growing and unmet demand for genital plastic surgery in the United Arab Emirates, Gary Alter, MD, Calif., expanded his practice last fall and joined the Nova Clinic in Dubai, comprised of plastic surgeons from all over the world in various subspecialties.

Dr. Alter, who splits his time between his primary office in Beverly Hills and part-time office in Manhattan, plans to practice at Nova three times each year to perform female and male genital aesthetic surgery. Due to the distance between Dubai and the United States and visa issues that patients can have, Dr. Alter says surgeons sometimes need to go to the patients, instead of patients going to the surgeons.

"The Dubai clinic makes it very convenient," he says.

To effectively manage his busy schedule and caseload as a bi-coastal and international plastic surgeon, Dr. Alter says he only performs what he considers minor, as well as noninvasive, procedures in Dubai or New York – which decreases the risk of postoperative complications.

"I limit the surgeries I do away from my primary office, so I know my patients won't need prolonged, immediate follow-up," he says. "I mainly perform genital aesthetic surgery in New York and Dubai, so I'm extremely confident there won't be any postoperative issues. If so, I can handle any issue over the phone or with photos through email, but it's very uncommon to run into complications. I have local surgeons who can provide follow-up care after I leave if anything comes up. That rarely happens, but they're available if needed."

Still, even though Dubai is becoming a hotbed for international travel and work, Dr. Alter says that any plastic surgeon considering work there should prepare himself or herself for a lengthy credentialing process and an oversaturated market.

"There are more plastic surgeons in Dubai than Beverly Hills or L.A.," he says. "Someone shouldn't expect to go there only to make money. I think that's a fallacy. You'll have to build a practice just like anywhere else, and it's a challenge just like opening a practice in your home base. You must be willing to be away from home and practice in a different environment."

Daniel Kaufman, MD, traveled to Dubai for three years to perform cosmetic surgeries before recently calling quits on it. Although he tells PSN he enjoyed traveling and building exposure in another country, the time away proved too taxing on his New York practice – and the professional rewards ultimately did not outweigh the challenges.

"The support system I set up in both countries definitely made it doable for three years, but it's so tiring and physically demanding," he says. "I had a rule that I wouldn't operate on anyone a week before I left, because I didn't want to leave them behind. It's just concerning to operate and then leave town right away. I like to follow-up on my own patients."

Dr. Kaufman frequently consulted with his international patients via VSee, a HIPAA-compliant telehealth app, before traveling to Dubai with a group of American board-certified plastic surgeons. His trips often lasted up to two weeks, depending on the cosmetic procedures scheduled during his stay. He says scheduling and finding local and trustworthy plastic surgeons in international territories are necessary to survive, but this can be difficult to manage.

"I wouldn't do a mommy makeover if I'm leaving the country in two days, but breast augmentation is doable unless an emergency comes up," says Dr. Kaufman, who adds he's not opposed to returning to Dubai to practice in the future. "It requires a lot of teamwork, so make sure you trust the people you're working with who know the community and the legalities of running a medical practice in that country. You have to rely on others to do a lot of the preoperative and postoperative care because you can't be everywhere at all times. I think it takes a special breed of surgeons to do reverse medical tourism. It's not for everyone."

The multidisciplinary approach

In 1994, after completing a plastic surgery fellowship at George Washington University Hospital in Washington, D.C., Daniel Ness, MD, Gastonia, N.C., founded Piedmont Plastic Surgery. Just six years later, he noticed that his community, on the periphery of Charlotte, N.C., was quickly losing dermatologists.

"In a span of one year, three derms left our area or stopped practicing, leaving only one," he says.

He also realized that bringing them into his plastic surgery practice would benefit his organization and the patient population. Today, Piedmont boasts 10 plastic surgeons, 17 dermatologists (including four Mohs providers) and eight PAs, the latter of which "are made much more functional in this practice model," Dr. Ness says.

"I was in a solo practice, followed by a two-person practice here at Piedmont," he adds. "This hybrid practice by far works best."

Nevertheless, he recalls that the hiring landscape is different today than what it was 18 years ago; specialty mergers may be embraced today, but recruiting is a lot more difficult, he says.

"The field of dermatology has been hit with a huge influx of venture capital/private equity money – and as a result, the salary expectations of established derms and those coming out of training have gone through the roof," Dr. Ness says. "It hasn't happened much in our specialty, but in dermatology, private equity is incredibly impactful. If you're trying to recruit a dermatologist today you either get lucky, or you pay a lot of money."

Still, Dr. Ness' efforts at the turn of the century were met with positive responses, and he says the Charlotte area was fortunate in that there weren't significant rivalries between the two specialties. It also helped to have nurtured good relationships with local dermatologists and plastic surgeons, many of whom ultimately joined Piedmont Plastic Surgery and Dermatology.

"Many of the providers in our practice were in their own practices in this service area before we merged, and I was on good terms with most of them," he says. "Keeping a good relationship and being on friendly terms with dermatology colleagues is unbelievably helpful. Refer patients to them and they'll refer to you, but make sure you give those patients back after you've treated them. It's very helpful for the two specialties to treat the other with respect."

To doctors considering opening their doors to other specialties in their practice, Dr. Ness says the key is bringing in strong talent – on the nonmedical side as well.

"If you start this process from scratch, the best advice I can give is to hire a good practice consultant – then start recruiting, and endeavor to map out your strategic plan and what you want to accomplish," he says. "These are complicated business arrangements, and our consultant gave us a lot of help. That paid dividends – many times over."

It doesn't always have to be plastic surgeons opening their doors to other specialties, either. John Lomax, MD, was enjoying his solo practice in Branson, Mo., when the urge struck to see what other opportunities might be awaiting a Midwestern plastic surgeon. He found a lead with a wound-care center that was seeking a director, so he made the necessary inquiries – one of which required him to complete a questionnaire to see the wound center's salary range.

That questionnaire brought him to the Soderstrom Skin Institute, a Peoria, Ill.-based practice headed by dermatologist Carl Soderstrom, MD, to which he's belonged since 2005.

"The wound-center recruiters knew that Dr. Soderstrom was looking for a plastic surgeon to meet his vision for the practice," Dr. Lomax says. "My perspective was that optometrists and ophthalmologists have a symbiotic relationship, and so should derms and plastic surgeons. Derms often have cases that are better-served by plastic surgeons and vice-versa, so why not combine the specialties and give patients the most efficient and effective experience possible?"

The process of joining Soderstrom Skin unfolded over several weeks, but once the parties agreed upon their working relationship, the details were handled quickly and simply, Dr. Lomax says.

"The recruiter insisted that I speak with Dr. Soderstrom, but I avoided that for several weeks," Dr. Lomax recalls. "Eventually I spoke with him – and I found that we shared a similar practice vision. Two weeks later, I visited the practice and it all came together."

Dr. Lomax says plastic surgeons considering a similar move should key on two concepts: The philosophy of the practice, and its approach to paying its medical professionals.

"The quality of care is something you must investigate before making any decisions," he says. "You're going to be grilled by those making the hiring decisions, so it's only fair that you grill them right back – this is your livelihood, career and reputation. Dig in deep, and learn what you can about the quality of that organization.

"Also, you want to know that you won't be 'the fifth wheel' in the practice – that you'll be utilized and allowed to practice as you'd like," Dr. Lomax says. "Plastic surgery must be an essential part of their business model."

Salary and other methods of compensation also provide clues as to the organization's philosophy, he adds.

"Dr. Soderstrom's vision is to build the practice by providing the physicians with an adequate salary but also to motivate them to work hard through a generous bonus structure," he says. "If a practice pays too comfortable a wage, people may not be motivated to work harder. My contract pays me well below plastic surgery's median income, but my bonus structure is such that I'm well above the median at the end of the day."

Large group practice

Following a six-year residency and microsurgery fellowship at New York University Langone Medical Center, Lisa Schneider, MD, says she wanted to find an academic practice. Due to family obligations, however, she was limited geographically, but at a dinner honoring one of her mentors at NYU, Joseph McCarthy, MD, she learned about The Institute for Advanced Reconstruction at The Plastic Surgery Center in Shrewsbury, N.J.

"I was interested in training and research," Dr. Schneider tells PSN. "I went into plastic surgery to pursue breast reconstruction and microsurgery. This practice really met those criteria for me a lot better than the hospital-based practices I was considering."

Dr. Schneider is one of 14 plastic surgeons (who are joined by a general surgeon, three breast surgeons and a vascular surgeon) that make up The Plastic Surgery Center. The "large group" practices (which also includes the Long Island Plastic Surgeon Group) are another alternative to an independent practice, or to joining a hospital or academic program.

In fact, Eric Wimmers, MD, who's also part of The Plastic Surgery Center, says the idea of striking out on his own after residency steered him toward a larger group.

"I was a little intimidated about the idea of doing solo practice," he concedes. "It sounded great to have that kind of autonomy, but I didn't know anything about billing, collections or any of the business side of medicine. This was the only place I interviewed."

Dr. Schneider says the amount of surgeons within the practice is a great educational resource.

"It's almost like residency fellowship-plus," she remarks. "You can be a functioning doctor and independent, but we have a lot of interesting meetings to discuss complex cases, and I'm able to work with this roster of experienced physicians. I learn so much from these senior doctors – even after office hours. It's not the kind of exposure you get in training – it's very much like ongoing education for me."

The Plastic Surgery Center ensures that all of its doctors have a subspecialty, some of which include phrenic nerve repair, brachial plexus repair, corneal reinnervation, lymphedema surgery, decompression for peripheral neuropathy and robotic surgery. Some of the work, Dr. Wimmers notes, would typically happen only at a university level, but the amount of collaboration among the doctors and the depth of knowledge throughout several subspecialties fosters a unique environment for innovation.

Although as any plastic surgeon working within a particular territory where other plastic surgeons work knows, competition is always a factor. In a large group practice, Dr. Wimmers says they must be extra mindful not to take patients or referrals from peers.

"Even two plastic surgeons working in the same hospital can lead to conflict," he says. "Traditionally, I think that may be why plastic surgeons tend to go into solo practice."

To curb infighting among a large group, Dr. Wimmers says The Plastic Surgery Center operates by two primary rules: divide doctors into different geographic territories, and don't take patients from other surgeons in the practice.

"It's very easy to step on someone else's toes – and that's where group practices can have difficulty," he says. "I'm the primary plastic surgeon in the Princeton region, but there are several other surgeons in our group who have privileges in this hospital if I'm doing, say, a double free flap or some complex procedure. You just have to be mindful about interactions with other doctors' patients."

Although both Dr. Wimmers and Dr. Schneider say that large group practices could become more prevalent throughout the country in the coming years, they also say the success of the large group is not just based on finding a common place of employment for surgeons.

"It's not just the model of the practice – it's running it on a daily basis," Dr. Schneider says. "You have to combine and recruit people who can form a high-level approach to plastic surgery with a high-level understanding of business."