SS 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.

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.

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.

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.

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 compartmentalizing. In his case, he picks one night a week where he does it until late of night and he doesn’t go home until everything on the administrative side is done then for the rest of the week, he sets up tasks and completes as many as he can. But when those tasks pile up, they will get all done on that one day. Otherwise, you can get pretty overwhelmed going from task to task to task so it's nice to have some structure in your day.

[15:35] Taking Calls

As a plastic surgeon, you don't have to take a lot of calls. It actually depends on where you are geographically located. Some hospitals require you to take a certain amount of call depending on the size of the call pool and how busy the hospitals are.

But Victor is not required to take any call whatsoever, but it also depends. He explains that there are some financial compensation at some sites while others don’t so it's just part of requirement-maintaining privileges. Although there is no requirement in the San Diego area where he is practicing, Victor is participating.

In terms of the percentage of patients he sees ending up in the operating room, his goal is close to 100%. He has seen surgeons who are well-established and basically they are turning patients away.

Victor has patients who are not good candidates and he tells them that they are not appropriately going to be surgical patients. But he enjoys the fact that he gets to educate a lot of the patients coming in. He spends over an hour in his consultations with patients giving them all the facts including the raw details and the scary things that can happen in surgery in order for them to make an informed decision.

At this point, he doesn’t feel that half of them are going to the operating room because they're just still in that information gathering stage. But as careers progress and you become very well known for particular surgeries or techniques, a lot of patients coming in have already done their homework and research. Especially with the availability of resources on the Internet, they've done their background on you. They know where you trained, they know what technique you do, and they've come specifically for that technique or procedure, and that ratio of conversion is much higher.

[18:10] Work-Life Balance

Victor describes having a good work-life balance whenever he chooses to have a good work- life balance. And that is very different from a lot of other physicians who are at the beck and call of their pager or their schedule, and therefore they don't have the same freedoms as he does. He can choose to work incredibly long hours or he can also choose not to be working those hours based on his specialty.

There are still emergencies and so he won't operate for weeks before he goes out of town and out of the country on vacation, but that's the only limitation. Nevertheless, he can choose within his personal setting to take time off to tend to himself and his health. However, he is also participating in community volunteering and spends time with his wife which he thinks are two very important things.

You're just going to get burned out, and that's an increasingly common phenomenon. Victor adds that good diet, nutrition, exercise, health maintenance, time with family, downtime are all things that should be scheduled and be consciously part of your day-to-day instead of things that are added on if you have time.

[20:35] Residency and Fellowship

Before you graduate to an otolaryngology head and neck surgery residency, it used to be an early match, and for many years now it's on time with everyone else's. It’s basically a five-year program which has an intern year but it's considered an integrated intern year. Typically at the same institution that you're doing residency, it does have general surgery components and rotations, however, increasingly more focused toward an ENT residency.

The elective months would be Anesthesiology. You'll be in the ER and you'll be doing surgical ICU, all geared toward skillsets that will be beneficial for your residency versus a standalone general surgery or where you are on rotations that are purely dictated by the general surgery department. This is commonly seen in orthopedics and other surgical subspecialties.

After which, there will be four years of ENT training. This may involve time at a children's hospital, at a VA institution, maybe a research block, but you'll be rotating through different sites and every year you're increasing your skillset. You're learning about all the systems, the ear, the nose, the throat, the different types of surgeries, seeing patients in clinic, and operating as well. But as you go through each year, your level of responsibility, and then as a Chief, you'll be running the service teaching and mentoring junior residents, and before you graduate you'll apply to a fellowship. This is typically within your fourth year.

There are a number of fellowships you can pursue such as pediatrics, neuroethology, head and neck cancer, microvascular reconstruction, facial plastic reconstruction, and sleep medicine even. So the fourth year is an application that goes in around January through March and you interview between March and end of May, and then you'll match to a one-year fellowship program that would go after your graduation from your ENT residency.

[23:37] An Alternative Route to Facial Plastic Surgery Outside of ENT

Victor explains that if you wanted to just do plastics in the face area, you could definitely reach that goal through an alternative route, which is through plastic surgery. There are two pathways through plastic surgery. The first one is to complete general surgery and then apply to a plastic surgery program. The second one is an integrated plastic surgery program that you match right out of medical school knowing you're doing plastic surgery and that has a general surgery component to it. These programs are typically longer with research years as well. Victor believes it can last as long as seven years to finish those residencies. And then most individuals who want to operate in the face area will go ahead and do an additional fellowship on top of that.

[25:00] Competitiveness in Matching

Victor describes matching in ENT has gotten to be one of the more competitive subspecialties to match.

Kids are applying to more colleges. College students are applying to more medical schools. Medical students are applying to more residencies. Even when he was applying, he met people who applied to every single ENT residency in the country just to play the numbers. And so it's more applications on the Residency Director's table to leaf through and make a selection.

In Victor’s case, they had a pretty small program. Only two residents are accepted per year, and maybe thirty people were applying per spot. Some programs only have one resident while big programs have four to five residents. And although some may say thirty people may not be a lot, but each one of those individuals have published research, phenomenal USMLE Step 1 score, letters of recommendation from the Chairman, have done research rotations, have really stacked their binder full of accolades.

There’s now an ENT student interest group that starts guiding students from the first day they get to medical school. And so it has gotten increasingly competitive to apply to any of these residencies. Victor feels ENT has a popular swing recently. It had a big swing before he applied, but it's always been up there along with the other types of subspecialties that are maybe competitive to get into.

[27:32] How to Be a Competitive Applicant

Victor outlines that in order to be competitive goes down to all the basic things that everyone is always striving for. This means maintaining good grades regardless if you're a pass or fail system. Getting into AOA as another marker on your application showing that you stand higher in your class than other students. Then the USMLE Step 1 score.

Before it was just about generally trying to get in some research but if you can get on a research project that is related to the residency that you want to apply to, that can only help more. Publications, participation, posters, presentations, attending meetings, getting involved in the department, attending conferences because there's always academic conferences every week within that department. Just make a personal connection with the attendings in that department. All of those things can make you more visible and create a level of investment, not necessarily to get you accepted into your home school's department, but also, they may be invested in getting you into their alma mater, or another program that they're aware of that would be a good match for you, or a geography that you're interested in.

But there's also a gamble. Victors knows of people who've done that and then decided they wanted to actually do a different specialty too so you're not locked into it. But if you know early on, that will behoove you to create those. Create that rapport, create that link to those individuals early so they can really get to know your medical school career.

[30:12] Osteopaths and Subspecialty Opportunities

Victor says there are only very few osteopathic ENT physicians out there. He has interacted with some and they're all great, but within the world of facial plastic surgery, it is still a very small community.

He thinks the majority are going down the MD path. However, the individuals operating in the head and neck facial area is growing. There are oral surgeons who perform cosmetic facial plastic procedures. There are general plastic surgeons who do those and there are those in the field of oculoplastic surgery who want to do face lifts and rhinoplasty. There are dermatologists who want to do more surgical procedures in the face. Then there are general surgeons, other surgeons who take cosmetic courses and get boarded under the Board of Cosmetic Surgery and perform those.

In terms of subspecialties available after ENT, there is a phenomenal opportunity to sub-specialize, not only by pursuing a fellowship but also many departments are strong in all fields within otolaryngology. It's not a necessity to have a fellowship training because it's not as formal. There isn't a required board certification for all the subspecialties, not all of them are ACGME certified either.

You can pursue a fellowship in facial plastic and reconstructive surgery, head and neck cancer with or without microvascular reconstruction, pediatric otolaryngology, otology or neuroethology that involves an ear surgery, sinus rhinology, laryngology professional voice. If an individual has graduated and they've had strong training, they can go out and they can become a sub-specialist. They can focus their practice doing laryngology professional voice in an area that needs it and provide that care at that subspecialty level without fellowship as long as they're adequately trained and have a desire to pursue those patients. But Victor says this is rare.

Most times, even those who are really focused, even nationally known for a particular field, those guys are always interested in doing other aspects of ENT as well. Some are doing more trauma, some may be doing head and neck cancer or they may be doing endocrine surgery but they're known for voice. They may be filling other roles within their group practice. Most of the otolaryngologists that Victor has met often miss doing other aspects, but find that, there’s no one else who's stronger in ear surgery so a lot of the ear cases go to that surgeon within the practice. Or someone else really enjoys sinus surgery, is savvy with it, is up with the latest techniques, and so that practitioner in that group will see more of those patients.

But each and every one of the ENT doctors in that group is less likely to solely focus on a subspecialty and only, only do that. Most of the times it will be a little bit more well-rounded and be doing multiple aspects of ENT, but not necessarily all of them. Victor concludes it's getting tougher and tougher to be in overall general unless you're in a more remote area where there's fewer practitioners around.

[35:06] Board Exams, Certifications, and Pass Rates

Victor illustrates the board exam as consisting of a written and an oral exam component. The current format are separate examinations. At one point in time, they were done on the same setting, but currently you will take the written exam. I, it is a computer-based test that is administered in September following your June/July graduation from residency, and that is a multiple choice format test that tests all the aspects of ENT medicine and surgery. There is a pass/fail threshold for that test, and those who pass may go on to the April exam which is currently administered in Chicago. There are five rooms with a number of three or four modules in each one, and it's basically a mock simulation clinical case. They're integrating some technology CT scans. They used to give you photographs but now you can get a computer screen and you can flip through a couple slides of a CT scan, or lab tests, or histopathology, and you went through a case from, say, the patient presents as a child or an adult who had a car accident, or someone who's lost their voice, and then you ask questions, you proceed through the case, and you gain points based on your questions and responses. Then hey tally those up and then once you've passed both of those components then you're board certified for ten years.

Through that ten years, you're doing maintenance certification through online modules every year, and then at the tenth year, you're re-certified again. So that is the board certification process for otolaryngology. You can also get board certified in neuroethology sleep and facial plastic surgery, and those consist of both of a written exam, an oral exam, and in some cases collecting case reports of patients that you've operated on in the first couple years of practice.

The pass rates are pretty high for both exams. Although Victor doesn’t know the exact number, he thinks it’s less than 10% fail because there's quite a bit of preparation for these exams.

[38:10] Working with Primary Care and Other Physicians

Victor still gets to work with primary care physicians whenever he sees more of the general ENT type patients. He used to give a lecture to family medicine residents about HIV manifestations in the head and neck, and it's shockingly common, and this is from sores on the lip, to frequent sinus infections, to ear infections, skin lesions, lots of different changes in the head and neck area, and a primary care can pick them up if they're looking for them, and make the appropriate referral for both HIV specialists, infectious disease specialists, as well as an ENT doctor to get involved. So that's one of the things Victors thinks that can be missed, and it frequently is missed, but then can be detected and really initiate early care at that primary level.

Other specialties he gets to work closely with depends on Victor personally. There could be dermatologists if they're removing skin cancers. This is the closest in his personal practice. However, there are a lot of ENT specialist surgeons who work with the head and neck cancer doctors that will interact with medical and radiation oncologists, the ear doctors. The neuroethology training will interact with neurosurgery for skull-based surgery. In the Intensive Care Unit where you're doing larger surgeries, the head and neck cancer surgeons will see patients again, admitted to the ICU for laryngectomy or tracheostomy management.

Victor adds that there is a close connection with ENT doctors in general with primary care doctors for sure. Absolutely, and oftentimes there's an unfair and sort of inverse ratio. There's tons of primary care doctors and you get a lot of their patients into ENT specialists and there are just very few ENT doctors available. And even with jam-packed schedules, there may be months' long wait lists. But all the time, he’d talk to primary care doctors who really need to get someone in urgently they will always make their best effort to get those in and not have them on the waitlist.

[41:35] Special Opportunities Outside of Clinical Medicine

Victor says there's always lots of research going on with the basic science level looking at wound care, tissue healing, in addition to the types of different injectable products, hyaluronic acids, botulism toxins. There's a lot of these things called PRP, Platelet Rich Plasma, and other types of different materials that are being injected for stability, safety, efficacy, improving them. There is a number of possibilities to pursue research and development of these types of products.

Those who are more interested in the business side can become Chief Medical Officers for healthcare related corporations. There's actually a very small and probably should be more encouraged politically active doctors.

There are a lot of different opportunities based on what you're interested in. But there is always that idea of you're giving up that patient interaction and that normal typical doctor schedule, but maybe it's for more regular hours when you're becoming an executive in a corporation.

[43:55] What He Wishes He Knew Then

Victor attended Tufts Medical School and they had a great health professional MBA integrated program that didn't really hold you back from graduating under four years. Although he didn't participate in it, he still thinks it should be part of more the regular curriculum.

There are great doctors that can no longer practice because their practices get shut down and closed. Other individuals who have some phenomenal skillset and need to get out there, if there's this barrier that they can't set up their business and they don't think it's possible, or even you don't necessarily have to be a small business owner, but as a component within even an academic group or a multi-specialty group, if you don't understand the metrics of and the financial side of it, you can't practice effective medicine if you're running at a loss, and you're going to get shut down, and then what happens to all your patients?

Hence, Victor thinks the economic side of medicine really needs to be a core component in addition to biochemistry, genetics, anatomy, and physiology because it's inevitable. Medicine has become more and more business. It may not be desired to be that way, but it's a reality and physicians really need to understand how to run it effectively and how to protect their business so they can continue to give great care to their patients.

[46:05] The Best and Least Liked Part of Being a Facial Plastic Surgeon

Victor loves the fact that he has the ability to look at something that a lot of people think they understand well, and bring just another level of understanding, another level of treatment to it. For example, when people talk about breathing through their nose, some may attribute it to allergy while others to structural issue like a deviated septum. Victor stresses that alone takes a higher level of understanding of nasal physiology, and the anatomy, and diseases that affect it. But a lot of really well trained people will stop at that point and they may treat the allergy, they may fix the deviated septum, and the patient still has a breathing problem going on. This is where Victor comes in and he loves understanding the true nuances of the facial structure. He says having that ENT background gives him the understanding of all the functionality, all the moving parts, all the components that need to work day-to-day being normal.

Victor claims his best results are noses that have just gone away. The patient no longer notices that it's stuffy or they have difficulty breathing through it when they exercise, and they no longer stare in the mirror and look at their nose that they feel is so prominent, and some people feel like it makes them ugly. And so the greatest success for him is to see patients to have their nose essentially disappear and just be in harmony with the rest of their face. It's still their nose, it's not a beautiful or fantastic looking nose, it's just their nose. He loves the fact that they don't even have to think anymore about picking up a spray bottle, or an allergy pill because their nasal passageways are nice and open, and so they just go about and they do normal tests every day without a thought in their mind. Victor describes it as one of the pure joys of doing it that he notices and that the patient no longer has to worry about anything anymore.

On the flip side, Victor thinks trauma is tough but there's a great opportunity to really make a major improvement. Someone breaks their jaw, or shatters their eye socket, but there is a limit of what the end result can be because of the nature of the original trauma. You can always make improvements but you can't really get them to a truly better place.

Victor thinks maybe a multi-specialty kind of care type of thing can get someone who's come back from major trauma to really get them healthy again, because mentally or physically there are just limitations from just those initial insults that they can't really get back to their baseline.

If he had to do it all over again, Victor would still choose to do facial plastics. He loves what he does and he says he’s excited to get up every day to go and see what comes through the door and he thinks this will stimulate him for years and years.

At the same time, he would look for other additional skillsets such as check out a neuroethology fellowship as well as other things that would complement what he already does. Or he may get into facial nerve reconstruction therapies and then advance outside of that.

Victor feels blessed to be able to do this. He could have gone a lot of other ways and would have been fine, but if given the opportunity to go about this again, he would still pick the same residency, the same fellowship, and focus on the same things. Maybe small little tweaks here and there, but overall, that same path has been really beneficial for him. It has really played to his strengths and it has given him the skillset to be a successful practitioner.

[52:15] The Future of Facial Plastic Surgery

Victor isn’t sure if any major changes are coming to facial plastics whether in the technologies or just fundamental shifts in the way things are practiced. He admits though of being on social media, a lot of people are becoming aware of new products and technologies at a much faster rate. The initiation of that first treatment is getting younger and younger. There are twenty-year-olds getting Botox to prevent wrinkles and people getting surgery at a younger age. But the largest kind of shift going on around a lot of focus on non-invasive therapies such as energy devices, like injections to dissolve fat.

They're often short-lived and have unforeseen complications. They affect your ability to do things later. They burn bridges in treatment pathway.

One of the things is injection rhinoplasty. People are putting fillers in their nose, but fillers in the nose in that skin area don't behave as well or in the same way as it does in the other soft tissues of the face. Victor has even seen disastrous things like blood vessels being blocked off, and whole areas of the skin and tissue on the nose enclosing. And that can happen in other areas of the face. It will heal and leave with some scarring, but if it happens on the nose or near the eye, then you've lost more function.

Victor thinks it’s revving up toward these office procedures, and some are great, but then they're being expanded to use in replacement of tried and true therapies, and he thinks it'll surge but then people will see so many issues with it and then it will come back. There will be better technologies, there will be better equipment, there will be safer mechanisms out there, and all for the good. Victor adds that's how medicine has always been. There's always been sort of a pioneering technology, or thought, or philosophy, and then new techniques come out, and then they kind of push the threshold of risk and complication, and they back off, and then there's a new push as new developments come on the horizon. But that's how you progress, and improve, and come up with new therapies for diseases that previously never had any treatment. So it has to be done but just in a careful way and more informed way.

[55:30] Final Words of Wisdom from Dr. Chung

Victor’s advice to patients is to take some art classes. It's one thing to understand the anatomy, but if you can translate that anatomy and the structures from your brain to your hands, and using your hands, those are all good basic skills that can translate into being a better surgeon, and choosing when not to upgrade. Everyone will study hard and everyone will get a high score on the test, and everyone will strive to get that letter, but you need to find one or two things like sculpting, or drawing, or it might be music, or something to really keep yourself active and in a unique sense to keep yourself motivated. You may bond with some big name doctor one day who's going to write you a letter based on that unique activity that you do that not everyone else is doing.

[56:55] Final Thoughts

If you are interested in ENT, or otolaryngology, or even the specialty or subspecialty of facial plastic surgery, I hope this episode was interesting to you. I love these conversations, I learn so much from them even as a physician, so I know that you as a premed or a medical student are going to get a ton of great information from these conversations to help steer you in the right direction for your career.

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Transcript

Introduction

Dr. Ryan Gray: I'm excited to announce that The Short Coat Podcast has now joined the Med Ed Media network at www.MedEdMedia.com. The Short Coat podcasts are broadcasts from the amazing and intense world of medical school from the students at the University of Iowa Carver College of Medicine. Go check them out directly at www.TheShortCoat.com.
This is Specialty Stories, session number 12.

Whether you’re a premed or a medical student, you've answered the calling to become a physician. Soon you'll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.

My name is Dr. Ryan Gray and if this is the first time you are joining me, this is not how my voice sounds normally. I just got back from a long podcasting conference, and I talked the whole time, and now my voice sounds like this and I think I have a cold on top of that too. So I apologize, but that's okay, the show goes on. I just want to mention one more time that the Short Coat Podcast, which is an amazing podcast put on by the students at the University of Iowa Carver College of Medicine, is now part of the Med Ed Media network. Go check them out at www.TheShortCoat.com.

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.

Meeting Dr. Chung in Facial Plastics

Dr. Victor Chung: My name is Victor Chung and I practice facial plastics and reconstructive surgery as a sub-specialty of otolaryngology; ear, nose and throat surgery.

Dr. Ryan Gray: What type of setting are you in? Are you academic or community setting?

Dr. Victor Chung: So I'm actually one of the rare breed of private practice, truly private practice solo by myself, the only physician in the office. And it's an interesting kind of hybrid situation where as a specialist I am affiliated with a number of the hospitals in the San Diego area, however I'm not officially on staff like in the hospital, always there all the time, but I do do consultation and coverage for call and operate at those sites.

Dr. Ryan Gray: What made you decide to go to the private practice route since it seems like the majority of physicians are pulling away from that?

Dr. Victor Chung: That's an absolute truth. Out of all the fellows who graduated in my year, only two of us went into true private practice and are opening practices. The majority are either joining multi-specialty practice groups, or- and even looking for academic jobs was a tradition and that's fallen by the wayside. My personal reasons is I had phenomenal training and I wanted to practice medicine the way I was trained to do it, and when you become part of a bigger group, and that may be a partnership even, as small as that, there's a level of compromise. Otherwise there's no way for you to be successful. You can't do everything your way and expect the other person to do it, and you can't have someone else expect you to do everything their way. And so to have that choice, that freedom to practice without restriction in a sense, delivering care the best of my ability, ordering the more expensive supplies, equipment, or employing a technique that I know how to do well, then that choice was natural for me in the sense that I had the luxury of being in a great personal situation that I could do that. So it's not a complete compromise when you join a bigger group, you join academics, but a lot of times you find that your patient population, or your group that you're in will dictate your niche and your future, and you may start doing things that don't make you necessarily happy anymore in medicine, and you start doing fewer of the cases that you like to do, or take care of the patients that you like. So you can find that ideal situation in academics in larger groups, but it's just more challenging.

Dr. Ryan Gray: Okay. How long have you been out in practice?

Dr. Victor Chung: So I've been out in my own practice officially doors opened just over twelve months. It took me a number of months just to get my place set up; a lot of logistics, and a lot of things they don't teach you in medical school, or residency, or fellowship about applying for business licenses, and insurance, and all the other type of regulations that are necessary to own and run a successful and safe business.

Dr. Ryan Gray: When did you know you wanted to be a facial plastic surgeon?

Dr. Victor Chung: I don't know if there was an exact point in time. In medical school, I always knew I was going to do surgery. I enjoyed that aspect of thinking, the hands-on aspect of it, the culture, the lifestyle, that was all agreeable to me. Now honing into a particular specialty was tough. I was looking at a number of sub-specialties that operate in this area; ophthalmology, neurosurgery, plastic surgery craniomaxillofacial, and the ENT. And when it came down to it, I found that the ENT sub-specialty really appealed to me because there were so many aspects that were different, even within a single focus of the human body it was challenging. And facial plastics is although 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, and that's encouraged by the overall academy. And those 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. And I find that the ET specialty overall gives you all the skillsets you need and as an individual you get to pick the things that you are comfortable with, or you really enjoy doing and focus on those, and oftentimes 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 don't as much, and so there's a 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.

Traits of a Good Facial Plastic Surgeon

Dr. Ryan Gray: What traits do you think lead to being a good facial plastic surgeon?

Dr. Victor Chung: It's a very particular skillset because you're talking about someone who needs to be both left brain and right brain. You need to be analytical and very objective in a sense, and understanding proportions, and direct measures and changes in that sense, but also someone who has an artistic component in how they think about things, how they view things. And so when I perform a rhinoplasty surgery, I am not only looking at this overall picture. So it's just not just a nose and a good shape nose, but I have the entire face prepped in the field exposed. I'm looking at the relationship of the nose to the chin, the forehead, proportions to how wide the eyes are, and that overall esthetic, but in addition as a confirmatory measure, I do all these different measurements how far the nose projects out, the angles, and those are within accepted values. So you need to be able to mind both sides and not be locked into either one, and be able to produce something that- people have to- it's right in the middle of your face, it's very obvious, so I think the stakes are a little bit higher.

Dr. Ryan Gray: As you came down to the decision to go into ENT, were there any other specialties that were close in the running, or had you made that decision at that point?

Dr. Victor Chung: No I actually had not picked my residency specialty until very late in the process. I had gone through most of the clinical clerkships of my third year thinking that I was leaning toward maybe orthopedic surgery as just a specialty within surgery. I didn't think I was going to do general surgery, but I did know it was some sort of surgical hands-on one. But at the time also interventional procedures were getting big. Interventional radiologists and cardiologists, they have very hands-on, very three dimensional stereotactic type specialties as well. But when I was thinking about which one to hone in on, I didn't get that exposure until in maybe the last quarter of the third year clinical clerkships, but it did turn around and I just got to interact with some very stimulating cases the same time as very nice residents who were open to sharing what they were doing and allowed me to participate, and inspirational attendings. And so it always happens to be sometimes that magic combination, but I always tell students who are trying to figure out what they want to do for the rest of their lives that 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? What are the patients that come in that can be on the side of some people say painful, or take up extra time, and make people sort of shutter in thinking like, ‘Oh no, I'm going to see a bunch of those today.' See if you're okay with that, and in the specialty of ENT, boogers and earwax, that's what I tell people. Like if you have no problem with those bodily fluids, then you'll be okay. Some people's aversion is blood, other people, they don't like eyeballs, they don't like stool. That's not- so you've got to kind of 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. And so I tell students all the time that, ‘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.' Spine surgeons, they have low back pain, 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 each specialty I tell students to examine, find those highlights, but also find- what are the low points and if you're okay with those.

A Day in the Life

Dr. Ryan Gray: Yeah. What types of patients do you treat?

Dr. Victor Chung: I see all kinds of patients, and that's what really keeps me captivated and stimulated in my specialty. You know it goes from very minor, very cosmetic, there's 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. And yet people gain quite a bit of benefit from them; attitudes change, self-esteems improve with the subtle thing that bothered them that maybe no one else noticed. But on the other end, I'm still participating in general ENT call. I'm doing tracheostomies for people who have lost their airway, I'm doing reconstructions for people who have lost major tissue from skin cancers or other disease or trauma, and so those are very drastic changes to improve someone's function and there's very little cosmetic aspect of that. And so I like that spectrum, I don't think I'll ever really give up doing all those things. I don't do much for ear tubes anymore, that's probably the most minor surgery you can do, but I like that full gamut of complexity and simplicity, because you can gain benefit for your patient on both ends.

Dr. Ryan Gray: Describe a typical day for you.

Dr. Victor Chung: Well, being new in my practice, every day is pretty variable at this point in time. The idea is a clinic, a private practice based practice, and so the majority of my patients would be seen in the office setting in a combination of consultations, follow-up visits, minor procedures, injections- injectables, those types of visits all in the office. As the trends go, more and more surgeons are doing things in the office. Typically a surgeon in my 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 in my specialty, so most of those patients are going home, but you know a select amount would be seen in the hospital as an inpatient and seen on multiple visits in the hospital before they're released. So- but in addition to that, what a lot of people and a lot of students and a lot of doctors don't realize is the business side of it. And so you can fill an entire day with administrative tasks, but it is about prioritizing and compartmentalizing. So I do pick one night a week where I have a late night and I don't go home until everything on the administrative side is done, and the rest of the week I set up tasks and I complete as many as I can, but when those pile up then they get all finished on that one day. Otherwise you can get pretty overwhelmed going from task to task to task, so it's nice to have some structure here in your day.

Taking Call as a Facial Plastic Surgeon

Dr. Ryan Gray: Do you have to take a lot of call?

Dr. Victor Chung: You don't have to take a lot of call, it actually depends on where you are geographically. Some hospitals require you to take a certain amount of call, it all depends on the size of the call pool, and how busy the hospitals are. And so by requirement I'm not required to take any call whatsoever, but it also depends, there is some financial compensation at some sites and other ones there is no compensation and it's just part of requirement maintaining privileges. So in the San Diego area where I am practicing, there is no requirement, but I'm participating.

Dr. Ryan Gray: As a surgeon, what percentage roughly of patients that you see in the office are you actually ending up doing surgery on?

Dr. Victor Chung: The goal is close to 100%. You know I've seen surgeons who are well-established and basically they are turning patients away. You want to get to that point in your career where you are selecting patients who they're the most appropriate, that you can exercise and perform the best surgeries for the best results, and then I have my patients who are not good candidates in telling them that they are not appropriately going to be a surgical patient. Initially it's not in that ratio, it's a lot of patients are coming in and they're getting educated, and I enjoy that, I spend over an hour in my consultations with patients, and not for the point of pushing them, or encouraging them, or coercing them into surgery, but to give them all the facts and the raw details, the scary things that can happen in surgery so they can make an informed decision. So at this point I don't feel that half of them are going to the operating room, because they're just still in that information gathering stage, but as careers progress and you become very well known for particular surgeries or techniques, a lot of patients coming in have already done their homework and research, especially with the availability of resources on the Internet, they've done their background on you. They know where you trained, they know what technique you do, and they've come specifically for that technique or procedure, and that ratio of conversion is much higher.

Work Life Balance

Dr. Ryan Gray: So probably not the best question for somebody that's brand new in practice and trying to get established, but what is your work life balance of like do you feel you have a good work life balance?

Dr. Victor Chung: I have a good work life balance when I choose to have a good work life balance. And that is very different from a lot of other physicians who are at the beck and call of their pager or their schedule, and therefore they don't have the same freedoms I do. So I can choose to work incredibly long hours, or I can choose not to be working those hours based on my specialty. There are still emergencies and so I won't operate for weeks before I go out of town and out of the country on vacation, but that's the only limitation honestly when I can choose within my personal setting to take time off to tend to myself, to my health, maintain- this is the first time in my life I'm making regular appointments to my own physician and catching up and getting blood tests and doing those things. But I'm also participating back in community volunteering and spending time with my wife which is- all those things I think are very important and a higher focus with younger and newer doctors than I think it's been official for a more long-lasting career. The idea that you can just go out and just work, work, work, work, work and see as many patients as you can. And there's value to that, but when you start sacrificing your own personal health, your interpersonal relationships, then you're not going to be as healthy of an individual and therefore not a good doctor over the long run. You're just going to get burned out, and that's an increasingly common phenomenon. You hear about- you're talking about cardiothoracic surgeons, you're talking about all specialty's doctors burning out depending on their situation, maybe not maintaining themselves. So I think good diet, nutrition, exercise, health maintenance, time with family, downtime are all things that should be scheduled and consciously part of your day-to-day instead of things that are added on if you have time.

Residency & Fellowship

Dr. Ryan Gray: What does the residency and fellowship path look like for somebody in your position?

Dr. Victor Chung: It's pretty standard. Basically out of medical school you'll be applying- I mean before you graduate to an otolaryngology head and neck surgery residency, it used to be an early match, and for many years now it's on time with everyone else's- all the other programs essentially. It is a five year program, it does have an intern year but it's considered an integrated intern year. Typically at the same institution that you're doing residency, it does have general surgery components and rotations, however increasingly more focused toward an ENT residency. So the elective months would be Anesthesiology, you'll be in the ER, you'll be doing surgical ICU, all geared toward skillsets that will be beneficial for your residency versus a standalone general surgery or where you are on rotations that are purely dictated by the general surgery department. And that's commonly seen in orthopedics and other surgical sub-specialties. And then four years of ENT training, and so- and that may involve time at a children's hospital, at a VA institution, maybe a research block, but in a sense you'll be rotating through different sites and every year you're increasing your skillset. You're learning about all the systems, the ear, the nose, the throat, the different types of surgeries, seeing patients in clinic, and operating as well but as you go through each year, your level of responsibility, and then as a Chief you'll be running the service teaching and mentoring junior residents, and before you graduate you'll apply to a fellowship. So that's typically within your fourth year. There are a number of fellowships you can pursue; pediatrics, neuroethology, head and neck cancer, microvascular reconstruction, facial plastic reconstruction, sleep medicine even. And so during the fourth year is an application that goes in around March, January through March, and you interview between March and end of May, and then you'll match to a fellowship program, and that's for one year that would go after your graduation from your ENT residency.

Dr. Ryan Gray: With your current specialty, isn't there another path to get to where you are outside of ENT? Like if I just wanted to just do plastics, could I be a facial plastic surgeon with just a plastic surgery residency?

Dr. Victor Chung: Yes. If you wanted to just do plastics in the face area, you could definitely reach that goal through an alternative route, and that would be through plastic surgery. There are- and I'm not 100% certain because I haven't done it myself, but there are two pathways through plastic surgery. One is to complete general surgery and then apply to a plastic surgery program, and then there are also integrated plastic surgery programs that you match right out of medical school knowing you're doing plastic surgery, and that has a general surgery component to it. Those programs are typically longer with research years as well, I believe lasting as long as seven years to finish those residencies. And then most individuals who want to operate in the face area will go ahead and do an additional fellowship on top of that. So you can reach the same goal in a sense, the same practicing setting, but you'll just have other skillsets bringing to that job as well.

Dr. Ryan Gray: How competitive is matching to ENT and then I guess to facial plastics?

Dr. Victor Chung: ENT has gotten to be one of the more competitive sub-specialties to match. I think all of the surgical sub-specialties have gotten difficult because it's just a pure numbers game, just from any type of academic application. Kids are applying to more colleges, college students are applying to more medical schools, medical students are applying to more residencies, and so there were even when I was applying I met people who applied to every single ENT residency in the country just to play the numbers. And so it's more applications on the Residency Director's table to leaf through and make a selection. And so for- see we only had a pretty small program. Only two residents are accepted per year, and I'd say maybe thirty people were applying per spot, and maybe more or maybe less than that. Some programs only have one resident, big programs have four to five residents. And although some may say thirty people may not be a lot, but each one of those individuals have published research, phenomenal USMLE Step 1 score, letters of recommendation from chairmans, have done research rotations, have really stacked their binder full of accolades. And I started thinking about it in my clerkship year, but a lot of the junior residents from my residency program, they were thinking about it from their first year of medical school. And there's now an ENT student interest group that starts guiding students from the first day they get to medical school. And so it has gotten increasingly competitive to apply to any of these residencies, and ENT I feel has a popular swing recently, it had a big swing before I applied, but it's always been up there with along with the other types of sub-specialties that are maybe competitive to get into.

Dr. Ryan Gray: What should a student be doing to be a competitive applicant?

Dr. Victor Chung: Well it's all the basic things that everyone is always striving for. So maintaining good grades regardless if you're a pass or fail system, getting into AOA as another marker on your [Inaudible 00:27:51] showing that you stand higher in your class than other students. But then after that- and then the USMLE Step 1 score. After that it can be- you can have a unique focus in a sense. Before it was just about generally trying to get in some research but if you can get on a research project that is related to the residency that you want to apply to, that can only help more. Publications, participation, posters, presentations, attending meetings, getting involved in the department, attending conferences because there's always academic conferences every week within that department. Just making a personal connection with the attendings in that department. All of those things can make you more visible and create a level of investment from those- not necessarily to get you accepted into your home school's department, but also they may be invested in getting you into their alma mater, or another program that they're aware of that would be a good match for you, or a geography that you're interested in. So it is a time investment, it is because you're spending so much time already studying, and trying to do all those basic things, but by investing yourself personally, that will I think give you an additional edge. But there's also a gamble. I know people who've done that and then decided they wanted to actually do a different specialty too so you're not locked into it. But if you know early on, that will behoove you to create those- create that rapport, create that link to those individuals early so they can really get to know your medical school career.

Dr. Ryan Gray: So there in the world of medical schools and graduates, there are a lot less osteopathic physicians graduating. Do you see many osteopathic facial plastic surgeons out there?

Osteopathic Facial Plastic Surgeons

Dr. Victor Chung: No, there are very few osteopathic ENT physicians. I've interacted with some, they're all great, but within the world of facial plastic surgery, it is still a very small community and if the- I think the majority are going down the MD path. And so overall I've seen fewer, however the individuals operating in the head and neck facial area is growing. I mean there are oral surgeons who perform cosmetic facial plastic procedures, there are of course general plastic surgeons who do those, there are those in the field of oculoplastic surgery who want to do face lifts and rhinoplasty, there are dermatologists who want to do more surgical procedures in the face. And so- and then there are general surgeons- other surgeons who take cosmetic courses and get boarded under the Board of Cosmetic Surgery and perform those. So there are an increasing number of individuals out there who have not gone down a traditional path of training and are performing those procedures.

Opportunities to Sub-Specialize

Dr. Ryan Gray: You talked a lot about some of the sub-specialties out there. I don't know if you remember which ones you talked about, but in general what are the opportunities out there to sub-specialize after ENT?

Dr. Victor Chung: After ENT, there is a phenomenal opportunity to sub-specialize, not only by pursuing a fellowship but also many departments are strong in all fields within otolaryngology. And so it's not a necessity to have a fellowship training because it's not as formal, there isn't a required board certification for all the sub-specialties, not all of them are ACGME certified either. And so you can pursue a fellowship in facial plastic and reconstructive surgery, head and neck cancer with or without microvascular reconstruction, pediatric otolaryngology, otology or neuroethology involves an ear surgery, sinus rhinology, laryngology professional voice. I feel like I'm forgetting one, but you can do fellowships in those but if you have- if an individual has graduated and they've had strong training, and they can go out and they can become a sub-specialist. They can focus their practice doing laryngology professional voice in an area that needs it, and provide that care at that sub-specialty level without fellowship as long as they're adequately trained and have a desire to pursue those patients. And so- but that's a rarity. Most times, even those who are really focused, even nationally known for a particular field, those guys are always interested in doing other aspects of ENT as well. Some are doing more trauma, some are- they may be doing head and neck cancer, they may be doing endocrine surgery but they're known for voice. They may be filling other roles within their group practice, and so most of the otolaryngologists that I've met often miss doing other aspects, but find that, ‘Well there's no one else who's stronger in ear surgery,' so a lot of the ear cases go to that surgeon within the practice. Or someone else really enjoys sinus surgery, is savvy with it, is up with the latest techniques, and so that practitioner in that group will see more of those patients. But each and every one of the ENT doctors in that group is less likely to solely focus on a sub-specialty and only, only do that. Most of the times it will be a little bit more well-rounded and be doing multiple aspects of ENT, but not necessarily all of them. It's getting tougher and tougher to be in overall general unless you're in a more remote area where there's fewer practitioners around.

Dr. Ryan Gray: What do the boards look like for you?

What the Boards Look Like

Dr. Victor Chung: The board exam is- there is a written and an oral exam component. The current format are separate examinations. At one point in time they were done on the same setting, but currently you will take the written exam, it is a computer-based test that is administered in September following your June / July graduation from residency, and that is a multiple choice format test that tests all of your- all the aspects of ENT medicine and surgery. And there is a pass fail threshold for that test, and those who pass may go on to the April exam where currently administered in Chicago, and right now I believe there are five rooms with a number of three or four modules in each one, and it's basically a mock simulation clinical case. They're integrating some technology CT scans- they used to give you photographs but now you can get a computer screen and you can flip through a couple slides of a CT scan, or lab tests, or histopathology, and you went through a case from- the patient presents as a child or an adult who had a car accident, or someone who's lost their voice, and then you ask questions, you proceed through the case, and you gain points based on your questions and responses, and they tally those up and then once you've passed both of those components then you're board certified for ten years, and then through that ten years you're doing maintenance certification through online modules every year, and then at the tenth year you're re-certified again. So that is the board certification process for otolaryngology. You can also get board certified in neuroethology sleep and facial plastic surgery, and those consist of both of a written exam, an oral exam, and in some cases collecting case reports of patients that you've operated on in the first couple years of practice.

Dr. Ryan Gray: Do you know what the pass rates look like?

Dr. Victor Chung: The pass rates are pretty high for both exams. I can't give you a number though, I'd say I think less than 10% fail because there's quite a bit of preparation for these exams.

Working with Other Physicians

Dr. Ryan Gray: What do you wish- it's a little bit harder I think for facial plastics. A general question I ask, what do you wish primary care providers knew about your specialty to better help you do your job? But I'm guessing that you don't interact much with primary care providers.

Dr. Victor Chung: I still do when I see- more for the general ENT type patients. I don't know if it's as much of a tangent, but I do- I used to give a lecture to family medicine residents about HIV manifestations in the head and neck, and it's shockingly common, and this is from sores on the lip, to frequent sinus infections, to ear infections, skin lesions, lots of different changes to- that present in the head and neck area, and a primary care can pick them up if they're looking for them, and make the appropriate referral for both HIV specialists, infectious disease specialists, as well as an ENT doctor to get involved. So that's one of the things I think that can be missed, and it frequently is missed, but then can be detected and really initiate early care at that primary level.

Dr. Ryan Gray: What other specialties do you work the closest with?

Dr. Victor Chung: It depends on me personally. There could be dermatologists if they're removing skin cancers. That's probably the closest in my personal practice, however there are a lot of ENT specialist surgeons who work with the head and neck cancer doctors, will interact with medical and radiation oncologists, the ear doctors- the neuroethology training will interact with neurosurgery for skull-based surgery. And so in the Intensive Care Unit where you're doing larger surgeries, the head and neck cancer surgeons will see patients again, admitted to the ICU for laryngectomy or tracheostomy management. But interestingly, a fair number of patients are generally on the healthier side, and a number of procedures we're doing are for improved quality of life; for better breathing, better functioning. And so there's a close connection with ENT doctors in general with primary care doctors for sure. Absolutely, and oftentimes there's an unfair and sort of inverse ratio. There's tons of primary care doctors and you get a lot of their patients into ENT specialists and there are just very few ENT doctors available, and even with jam-packed schedules there may be months' long wait lists. So that interaction- but all the time I'll talk to primary care doctors who really need to get someone in urgently, and we'll always make our best effort to get those in and not have them on the wait list.

Opportunities Outside of Clinical Medicine

Dr. Ryan Gray: Are there any special opportunities outside of clinical medicine for facial plastic surgeons?

Dr. Victor Chung: Outside of clinical medicine? Well I mean if you're talking about research, there's always lots of research going on with the basic science level looking at wound care, tissue healing, in addition to the types of different injectable products, hyaluronic acids, botulism toxins, there's a lot of these things called PRP, Platelet Rich Plasma, and other types of different materials that are being injected for stability, safety, efficacy, improving them. And so there is a number of possibilities to pursue research and development of these types of products. As for- I know a lot of- and this can go to any specialty physicians who get interested in other aspects. They become more interested in the business side, become Chief Medical Officers for healthcare related corporations, there's actually a very small and probably should be more encouraged politically active doctors. There's Dr. Silver down in Atlanta, Georgia who had a fellowship, a very active surgeon who's gotten very active more in the political environment and stage. And so I think there's always lots of different opportunities that you can springboard from your specialty, especially when you get to interact in both- you could be in the private or academic setting, and you take that and translate your practice, and you know you're going to have to sacrifice clinical time, but you can- there are a lot of different opportunities based on what you're interested in. But there is always- you're giving up that patient patient interaction and that normal typical doctor schedule, but maybe it's for more regular hours when you're becoming an executive in a corporation.

What Dr. Chung Wishes He Knew Then

Dr. Ryan Gray: What do you wish you knew before going into facial plastic surgery?

Dr. Victor Chung: I think one of the major deficiencies in a doctor's education as the business side. At Tufts Medical School we had a great health professional MBA integrated program that really- it didn't really hold you back from graduating under four years, and I didn't participate in that but I think it should be part of more the regular curriculum. As this business side can really- if you have a poor understanding of the business side of medicine, there are great doctors that can no longer practice because their practices get shut down and closed, and other individuals who have some phenomenal skillset and need to get out there, if there's this barrier that they can't set up their business and they don't think it's possible, or even you don't necessarily have to be a small business owner, but as a component within even an academic group or a multi-specialty group, if you don't understand the metrics of and the financial side of it, I mean again, you can't practice effective medicine if you're running at a loss, and you're going to get shut down, and then what happens to all your patients? So I think that business- the economic side of medicine really needs to be a core component in addition to biochemistry, genetics, anatomy, and physiology because it's inevitable. Medicine has become more and more business. It may not be desired to be that way, but it's a reality and physicians really need to understand how to run it effectively and how to protect their business so they can continue to give great care to their patients.

Best and Worst of Being a Facial Plastic Surgeon

Dr. Ryan Gray: What do you like the most about being a facial plastic surgeon?

Dr. Victor Chung: I love the fact that I have the ability to look at something that a lot of people think they understand well, and bring just another level of understanding, another level of treatment to it. So for example, when people talk about breathing through their nose, someone would say, ‘Well I can't breathe through my nose well.' And that may divide up between somebody saying, ‘Well they have allergies so it's [Inaudible 00:46:38].' Then other people will be like, ‘Well there's something structural going on, they have a deviated septum.' And that alone takes a higher level of understanding of nasal physiology, and the anatomy, and diseases that affect it. But a lot of really well trained people will stop at that point and they may treat the allergy, they may fix the deviated septum, and the patient still has a breathing problem going on. And that's where I come in and I really love understanding the true nuances of the facial structure because having that ENT background gives me the understanding of all the functionality, all the moving parts, all the components that need to work day-to-day being normal. But in addition, the additional training in facial plastics gives me the side of the aesthetics but also the skillset to create that structure, to improve the functionality while maintaining overall looks. So my best results are noses that have just gone away in a sense. The patient no longer notices that it's stuffy or they have difficulty breathing through it when they exercise, and they no longer stare in the mirror and look at their nose that they feel is so prominent, and some people feel like it makes them ugly. And so the greatest successes, and terrible for branding, but for patients to have their nose essentially disappear, that it just is in harmony with the rest of their face. It's still their nose, it's not a beautiful or fantastic looking nose, it's just their nose. And the fact that they don't even have to think anymore about picking up a spray bottle, or an allergy pill because their nasal passageways are nice and open, and so they just go about and they do normal tests every day without a thought in their mind. And so that's one of the pure joys of doing it that I notice it, I know what's going on there, but that patient no longer has to worry about a thing anymore.

Dr. Ryan Gray: On the flipside, what do you like the least?

Dr. Victor Chung: I think trauma is tough. I think there's a great opportunity to really make a major improvement. Someone breaks their jaw, or shatters their eye socket, but there is- it's kind of a limit of what the end result can be because of the nature of the original trauma. You can always make improvements but you can't really get them to a truly better place. And in addition I think there's a major psychological component related to trauma, so even with an improved physical state, mentally there's still a deficiency, there's still a pathology going on, and so I don't feel personally within my skillset to really get a patient really improved. And I don't know who does really, I think maybe a multi-specialty kind of care type of thing to really get someone who's come back from major trauma to really get them healthy again, because mentally or physically there are just limitations from just those initial insults that they can't really get back to their baseline.

Dr. Ryan Gray: If you had to do it all over again at this point, would you still choose facial plastics?

Dr. Victor Chung: Absolutely. Absolutely. I love what I do, I am excited to get up every day to go and see what comes through the door, and I think it will stimulate me for years and years. Interesting enough. If I won the lottery I would be able to definitely keep my practice running, but at the same time I would look for other additional skillsets. I would check out a neuroethology fellowship, other things that would complement what I already do. Maybe get into facial nerve reconstruction therapies and then advance outside of that. So it's always fascinating, it's always interesting, there are always more to learn from it and so I lucked into the path and where I ended up, and I was like truly blessed to do that. I could have gone a lot of other ways and I'm sure would have been fine, but if there- given the opportunity, I would go about this- I would pick the same residency, the same fellowship, focus on the same things. Maybe small little tweaks here and there, but overall that same path has been really beneficial for me, has really played to my strengths, has given me the skillset to be a successful practitioner.

What the Future of Facial Plastic Surgery Looks Like

Dr. Ryan Gray: Do you see any major changes coming to facial plastics whether that's technologies, or just fundamental shifts in the way things are practiced?

Dr. Victor Chung: Oh yeah, definitely for sure. Yeah I've been on social media, a lot of people are becoming aware of new products and technologies at a much faster rate. The initiation of that first treatment is getting younger and younger. There are twenty year olds getting Botox to prevent wrinkles, there are people getting surgery at a younger age, but the largest kind of shift going on around a lot of focus on non-invasive therapies. There's energy devices, there are injections to dissolve fat, but I think there's a little bit of oversell on those types of- anything that gets marketed as quick and easy, and when they add on cheap, quick and easy, those results don't- in my opinion ever really match the promises of the outcome that they get. They're often short-lived, they have unforeseen complications, they affect your ability to do things later, they burn bridges in treatment pathway. So one of the things is injection rhinoplasty, people are putting fillers in their nose, but fillers in the nose in that skin area don't behave as well- or in the same way as it does in the other soft tissues of the face. I've even seen disastrous things like blood vessels being blocked off, and whole areas of the skin and tissue on the nose enclosing. And that can happen in other areas of the face, but wound care, those will heal and leave with some scarring, but if it happens on the nose or near the eye, then you've lost more function. And so I think there's this- right now this revving up toward these office procedures, and some are great, but then they're being expanded kind of to use in replacement of tried and true therapies, and so I think it'll surge, and then people will see so many issues with it, and then it will come back. But then you can help the improvements of the technology; there will be better technologies, there will be better equipment, there will be safer mechanisms out there, and I think for the good. So I think that's how medicine has always been. There's always been sort of a pioneering technology, or thought, or philosophy, and then new techniques come out, and then they kind of push the threshold of risk and complication, and they back off, and then there's a new push as new developments come on the horizon. But that's how you progress, and improve, and come up with new therapies for diseases that previously never had any treatment. So it has to be done but just in a careful way and more informed way.

Words of Wisdom to Students

Dr. Ryan Gray: Any last words of wisdom for a student that's interested in facial plastics?

Dr. Victor Chung: Take some art classes, that's what I would say. It's one thing to understand the anatomy, but if you can translate that anatomy and the structures from your brain to your hands, and using your hands, those are all good basic skills that can translate into being a better surgeon, and choosing when not to upgrade. So always kind of rounding out [Inaudible 00:56:08]. Everyone will study hard and everyone will get a high score on the test, and everyone will strive to get that letter, but you need to find one or two things like sculpting, or drawing, or it might be music, something to really keep yourself active and in a unique sense to keep yourself motivated, and you may bond with some big name doctor one day who's going to write you a letter based on that unique activity that you do that not everyone else is doing.

Final Thoughts

Dr. Ryan Gray: Alright there you have it. If you are interested in ENT, or otolaryngology, or even the specialty or sub-specialty of facial plastic surgery, I hope this episode was interesting to you. I love these conversations, I learn so much from them even as a physician, so I know that you as a premed or a medical student are going to get a ton of great information from these conversations to help steer you in the right direction for your career.

If you enjoyed this podcast, I want you to do me one thing. Go share it with somebody. Go share it with your classmate, go share it with your advisor, go share it with whoever, go share it on your Facebook page. Actually this month as we're publishing this, NPR is doing something called #trypod where they're asking their listeners to suggest a podcast to their friends who don't listen to podcasts. So that's what I want you to go do. Just go suggest listening to podcasts to your classmates, to your friends, to your advisors, who may or may not already listen to a podcast.

I hope you have a great week, we'll catch you next week here at Specialty Stories.

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