12: A Private-Practice Facial Plastic Surgeon Shares His Story

Session 12

Dr. Chung is a solo private practice Facial Plastic Surgeon. He discusses his path through ENT residency and what he likes and dislikes about his job.

Today's guest on Specialty Stories is a solo private practice facial plastic surgeon. It's a great specialty, super sub-specialized specialty of ear, nose, and throat surgeons, or otolaryngology. And Victor, or Dr. Chung, is going to join us and tell us all about it.

[02:15] A Personal Choice to Be in Private Practice

Dr. Chung practices facial plastics and reconstructive surgery as a subspecialty of otolaryngology; ear, nose and throat surgery. He considers himself as one of the rare breed of private practice, truly private practice solo by himself, the only physician in the office which is an interesting kind of hybrid situation. As a specialist, he is affiliated with a number of the hospitals in the San Diego area, however, he’s not officially on staff who who has to be in the hospital all the time. Nevertheless, he does consultation and coverage for call and operate at those sites.

Out of all the fellows who graduated in his year, only two of them went into true private practice and are opening practices. The majority are either joining multi-specialty practice groups. He thinks even looking for academic jobs was a tradition that's fallen by the wayside.

As to why he chose private practice, Dr. Chung had his personal reasons. He had phenomenal training and wanted to practice medicine the way he was trained to do.

“When you become part of a bigger group or even as small as a partnership,  there's a level of compromise. Otherwise, there's no way for you to be successful.”

He further explains that what he likes in private practice is having that freedom to practice without restriction in the sense of delivering care to the best of his ability that gets to order the more expensive supplies and equipment or employ a technique he knows well. So his choice was natural for him and he sees being in a personal situation that he could do it is a luxury.

Although joining a bigger group or academics is not a complete compromise, Dr. Chung says that oftentimes, you find that your patient population or the group you're in will dictate your niche and your future. Then you may start doing things that don't make you necessarily happy anymore in medicine. You start doing fewer of the cases that you like to do or take care of the patients that you like. You can find that ideal situation in academics in larger groups, but it's just more challenging.

Victor has been out in his own practice just over twelve months. It actually took him a number of months just to get his place set up which involved a lot of logistics as well as a lot of things they don't teach you in medical school, or residency, or fellowship about applying for business licenses, insurance, and all the other type of regulations that are necessary to own and run a successful and safe business.

[05:36] His Interest in Facial Plastic Surgery

Victor always knew he was going to do surgery when he was in medical school. He enjoyed the aspect of thinking, being hands-on, its culture, and the lifestyle. But honing into a particular specialty was tough. He was looking at a number of sub-specialties that operate in the areas of ophthalmology, neurosurgery, plastic surgery craniomaxillofacial, and the ENT subspecialty, which he found very appealing.

“Even within a single focus of the human body, it was challenging. And although facial plastics is a sub-sub-specialty within it, it's still an integrated part.”

You will go out in the community and meet physicians who are ENT-trained, but not fellowship-trained, but they are still practicing as facial plastic surgeons. This is actually encouraged by the overall academy. The types of procedures can be reconstructing cancer that may have been excised on just the skin level, but others are doing larger reconstructions or rhinoplasty and face lift based on their skillset and their comfort level.

Victor adds that the specialty overall gives you all the skillsets you need, As an individual, you get to pick the things that you are comfortable with  or you really enjoy doing and focus on those. Additionally, you'll meet other physicians in your community who like doing the other procedures that you may feel less comfortable with or ones you don't like as much. Victor points out the good camaraderie that goes on there and you're a lot happier treating the disease states and doing the surgeries that you like to do.

[07:50] Traits of a Good Facial Plastic Surgeon

Victor explains that you need to be both left brain and right brain. On one hand, you need to be analytical, be very objective, and be able to understand proportions and direct measures and changes. On the other hand, you have to be someone who has an artistic component in how you think about things and how you view them.

When Victor performs a rhinoplasty surgery, he is not only looking at this overall picture. So it's just not just a nose and a good-shaped nose, but he has the entire face prepped in the field exposed. He looks at the relationship of the nose to the chin, the forehead, proportions to how wide the eyes are, and that overall aesthetic. Moreover, as a confirmatory measure, he does all these different measurements as to how far the nose projects out, the angles, and those that are within accepted values. So you need to be able to mind both sides and not be locked into either one. It's right in the middle of your face, it's very obvious, so the stakes are a little bit higher.

[09:28] Other Specialties in Mind

Victor had not picked his residency specialty until very late in the process. He had gone through most of the clinical clerkships of my third year thinking that he was leaning toward orthopedic surgery as just a specialty within surgery. He didn't think he was going to do general surgery, but he knew it was some sort of surgical hands-on one.

At that time too, interventional procedures were getting big. Interventional radiologists and cardiologists have very hands-on and very three-dimensional stereotactic type specialties as well. But thinking about which one to hone in on, Victor wasn’t exposed to it until the last quarter of the third year clinical clerkships. And it did turn around having interacted with some very stimulating cases as well as with nice residents and attending physicians who were open to sharing what they were doing and allowing him to participate.

If you’re considering ENT, Victor recommends that you see if you're okay with boogers and earwax and all those bodily fluids. If you have no problem with them then you'll be okay. He explains how people have aversions to different things. So you have to pick what you’re comfortable with seeing everyday. You can't just base that purely on a good experience. You need to figure out what is the day-to-day kind of drudgery.

“Pick what you are comfortable with seeing day to day, because if you don't like your day to day, you're not going to enjoy the highlights any more.”

Victor tells students all the time check out the really dizzy patient that is struggling and you can't get a good exam on, but you still try to figure out how to treat them. It’s really, really tough sometimes to figure out if they're surgical or non-surgical, and yet they can take up more than a full appointment visit. So regardless of your specialty, be sure to examine, find those highlights, but also find what are the low points and if you're okay with those.

[12:20] Patient Types and Typical Day in the Life of a Facial Plastic Surgeon

Victor sees all kinds of patients, which is something that keeps him captivated and stimulated in his specialty. His patients range from very minor, very cosmetic to no medical emergency about it whatsoever, there's no urgency, it's purely elective, the changes are super subtle, super small, there's no life threatening thing that you're changing. Nevertheless, people gain quite a bit of benefit from them. Their attitudes change and their self-esteems improve with the subtle thing that bothered them that maybe no one else noticed.

Moreover, Victor still participates in general ENT call. He does tracheostomies for people who have lost their airway or reconstructions for people who have lost major tissue from skin cancers or other disease or trauma. These are very drastic changes to improve someone's function and there's very little cosmetic aspect of that. So Victor likes that spectrum and he doesn’t see himself giving up on doing all those things. Overall, he likes the full gamut of complexity and simplicity because you can gain benefit for your patient on both ends.

Being new in his practice, every day for him is pretty variable at this point in time. The idea is a clinic, a private-based practice, and so the majority of his patients would be seen in the office setting in a combination of consultations, follow-up visits, minor procedures, injections- injectables. Those types of visits are all in the office.

“As the trends go, more and more surgeons are doing things in the office.“

Typically, a surgeon in his specialty will have block time or days set aside where they would be operating, maybe two days a week being in the operating room doing a number of cases. But the majority of them would be on the outpatient setting so most of those patients are going home. A select amount would be seen in the hospital as an inpatient and seen on multiple visits in the hospital before they're released.

Moreover, Victor stresses how a lot of students and doctors don’t realize the business side of it. You can fill an entire day with administrative tasks, but it is about prioritizing and compart