SS 32 : A Community Plastic Surgeon Gives Us a Look at His Job

Session 32

Dr. Russell Babbitt is a Plastic Surgeon in private practice for the last seven years. He took the time to share with us his thoughts on what he likes and what he doesn't like about it and what you, as a premed or medical student, should start doing now to become a better applicant for Plastic Surgery.

[01:18] His Love of Plastics

Around that time when the show ER was popular, Russell started medical school thinking he wanted to do Emergency Medicine but realized it wasn't for him. Instead, he liked doing surgical rotation along with his plastic surgery rotation, which he describes as gelling very well. He also started college as an art major so the visual-spatial aspects really appealed to him once he got into plastics because it wasn't just a cookbook, do-this-do-that case; but it involves applying spatial problems to different situations which appealed to him. The second he got onto his plastic rotation, he knew it was where he needed to be.

Russell went to UMass for medical school and during their third year surgery rotations, they had a three-month block spent on general surgery and the other half was subdivided into other subspecialties. Many of them ended up rotating through plastics. Other specialties he did consider include general surgery and vascular surgery. He likes the disease processes in general and being able to intervene into a lot of different illnesses and have the ability to take care of sick people across the board. Ultimately, he was meaning to be a well-rounded surgeon and the fact that plastics builds on that was nice.

[04:30] Traits Leading to Becoming a Good Plastic Surgeon

Russell cites meticulousness as the primary trait of becoming a good plastic surgeon, as well as being a good visual-spatial thinker. Being a good communicator is also very important since you need to be willing to sit down with the patient and explain the disease process, the problems, the solutions, and how you're going to get there. Oftentimes, there are many ways to get there and there are many different things that can happen.

Russell further explains that the doctors who don't communicate tend to have more difficulties – regardless of what the outcomes are – and this is especially true in plastics. Beyond that, you also have to be a good technician and be able to develop a plan, know what you're going to do, see the technical problem you're going to solve and actually execute it.

Also, you must be able to see the long term outcome, not just the proper three-dimensional result but it has to look good in three to four months and years down the road. Blood supply also has to be intact at the end of the day. One of his mentors once told him that when he's out in private practice, one of the things he has to do is while doing a skin graft, you have to make sure every mitochondria survives.

Russell adds that another innate trait in a plastic surgeon is being anal. In terms of having an arts background, although its not necessary when you become a plastic surgeon, a lot of people that go into medicine in general tend to be very agile-thinkers. So, Russell thinks a lot of it can be taught. Personally he thinks it helps a lot in terms of little shortcuts that allows him to know what to do before he even thinks about it. This may also help in certain other areas where it would have been hard to to teach it.

[09:00] Types of Patients and Typical Day

Russell sees a mix of 50% cosmetic and 50% reconstructive patients. To his surprise, he's doing a lot of breast reconstruction. They have a very busy breast reconstructive program where he's the director at a local hospital. This was something he didn't expect to be doing a lot but he ended up doing it anyway.

The reason for breast reconstruction is almost always breast cancer in various stages. Or it may be due to genetic predisposition, where the patient has a high risk of developing breast cancer in the future. Perhaps the patient has an active diagnosis of breast cancer or very late stage precancerous lesions which would require mastectomy and therefore they would then need Russell to reconstruct the breast. He describes it as a very intense process and oftentimes, he is the one the patient sees the most of throughout the process. They see them after surgery and on a weekly basis to fill tissue expander that expands the breast's skin envelope after radiation and mastectomy. Nevertheless, Russell sees this as a nice aspect of what they do.

Another thing they commonly do is reconstruction after skin cancer resections with dermatologists; which can sometimes be very large defects. On the cosmetic side of things, they do a bit of facial cosmetics like face lifts, rhinoplasty, ear correction, fillers, Botox, facial rejuvenation, in addition to liposuction, tummy tucks, and a lot of breast surgeries.

Russell finds himself in the operating room at least two full days a week and even up to three full days a week. He works between 40 and 60 hours a week. During his office-only days, he gets in around 9 am and finishes around 6-7pm. His OR days start at 730am and finishes between 4 and 5pm. He does his larger cases first thing in the morning and then the local type cases like mole removals or lesion removals or skin cancer reconstruction in the afternoons.

Russell has an amazing physician assistant who has been with him for about two years now that sees a lot of his postoperative patients in the office. They are very much on the same page and because of the high demands, they've gotten so busier across the board. Nevertheless, they try to balance things out to avoid burnout and try to make it sustainable.

[15:00] Private Practice Goals for Work-Life Balance

Russell would like to have his weekends off, so he covers himself 24/7, 365 days except when he's on vacation. Other than that, he's available for patient issues that only he can answer, unless his PA is available to answer it. He doesn't do office hours on weekends and reserves it for family time. He tries to be home every night to help with the kids to bed and stuff. Pretty much, he's going all out throughout the week and works as hard as he can to get as many patients. Most importantly, he makes sure they're taking enough time with each patient.

One reason he shies away from being employed is he doesn't want to be in a position where he's being told how many people he has to see a day. He's okay with this perspective.

We're taking good care of them and that my bills are paid. Basically, this is how he likes to do it right now, compared to his colleagues. It's not how they're living, so he feel extremely fortunate for his balance.

[17:30] Patients that Go to the Operating Room

Russell estimates their conversion rate in the high 80%. These people come to his office because they want to see him and they're not doctor-shopping as much. They've waited a decent amount of time to see them so they're there to see him specifically and are typically there to have surgery. Also, nobody goes to the operating room without seeing him in the office first; with the exception of local anesthesia procedure where they get to meet him that day, he talks to them, and they'd have to wait for the procedure. But if somebody gets general anesthesia, they may see his PA first and then get a second appointment with him to have another formal sit-down discussion if they're going to go forward. He doesn't do internet-based consultations since it's not how he wants to do things in terms of how he wants to care for patients.

Russell says there are patients coming in who are insecure about something and they come to see you for that one thing.

Just because that one thing that bothers them, it doesn't mean there are other things that may be addressable as well. It is a strict policy in our office to not mention those other things or to try to market services the patient is not requesting.

In other offices, patients would come in for tummy tuck and then the surgeon there would ask you to consider getting a neck lift or breast done, or whatever. They basically walk in to talk about getting fillers in their lips and they walk out with $30,000 worth of clothes and a whole new complex because they didn't realize all those other things need to be addressed.

Practicing ethically and conscientiously, Russell sends a lot of people in the office telling them they don't need surgery and don't listen to anybody that tells you that you do. He emphasizes that this is the right thing to do because at the end of the day, they're still physicians that took an oath to do the right thing for people and he feels it's job to make sure that if people need to do surgery, it has to be done safely and in the right circumstances. He needs to do it well and do it safely. He needs to do it under the right circumstances for the right patients.

Russell admits he is bothered by a lot of plastic surgeons out there that are making a lot of decisions for financial reasons, impacting other people's lives negatively. They are doing surgeries for financial reasons, which makes them all look bad collectively. Often a reason plastic surgeons and cosmetic surgeons have a bad name sometimes.

[22:05] Taking Calls

Russell is in a position where he doesn't cover much calls at the surrounding hospitals. In metropolitan areas, most hospitals require being on call as a stipulation of privileges for credentials. Credentials means being allowed to use their operating rooms. He doesn't have to do that. The majority of what he does is at a freestanding ambulatory surgery center, which is a facility not attached to or affiliated with a hospital. But he still has to do everything that is like a major operation they do at a hospital. He also has a lower threshold for doing certain things in the hospital than some doctors do because it's cheaper to do things in an ambulatory center than it is to do at a hospital. He actually anticipated to take calls when he took the position he took but when he got there, he was told it wasn't necessarily expected. But he does stay on as a courtesy; like if he's available for something where if he can go, he will. So he's like “always on, but always not on.” This seems to work well and they like the fact he's available if he's available. Nevertheless, Russell describes having a symbiotic relationships with the ER, where he is available in the middle of the night if they need to call him and if they need to send a patient to his office later on for a suture removal.

[24:35] Residency and Fellowship Training

There are two typical approaches. One is to finish medical school and go into general surgery, neurosurgery, orthopedics, or ENT and then match after that into a plastic surgery fellowship. The other approach is matching into a categorical plastic surgery program, which is a dedicated program for plastic surgery. Neurology is the other pathway they can do it from.

In Russell's case, he did his general surgery program at UMass and transitioned into the plastic surgery program so it was more of a traditional approach. It was also a bit hybrid; because he was able to transition out after his third year general surgery being the only type of residency you can do it from.

With the traditional fellowship pathway, you don't have to finish general surgery but you have to finish all the other types of residencies before you go into a plastics fellowship. Russell was already at UMass for his general surgery training, did two years in the plastic surgery laboratory, and worked on various projects with them so he was a known commodity. Additionally, Russell says you have to be very competitive with the rest of the applying population. All in all, it was a seven-year pathway. Categorical might be six and then general surgery can end up being nine consisting of five years general surgery, two years of research, and two or three years of plastics although he thinks all plastic fellowships are now three years mandatory. Many will also do an additional year of hand fellowship because it's so competitive. The year he applied, there were only 92 plastic surgery fellowship spots in the country excluding the categorical spots but just post general surgery positions.

Plastic surgery is among the subspecialties in surgery that are the most competitive. Dermatology might be the only one most competitive in terms of everything else but in terms of the categorical spots, plastic surgery, Russell believes, may be the most competitive now.

[28:30] How to Be a Competitive Applicant

Russell illustrates that to be competitive, you have to set yourself apart by showing interest in plastics early on. The good sub-I's  pretty much have an inside track to the spot because it's a month-long interview. Some international students even spend extra time doing research and this makes a huge difference. You're much more like to want to match somebody that you know and you know is good.

Additionally, you want to show them that your hands are good and that you're conscientious and good with patients and the staff. Know that the staff can have a remarkable amount of power. The chairman's secretary is going to have more say in the ultimate decisions of who gets into the program than potentially the junior faculty.

You need to be nice to those people when you call or you're trying to coordinate something with the program since they have the ear of the program directors and the higher up's. Russell adds that we tend to focus a lot on research, volunteer work and stuff, but all that is part of the baseline. You have to be good at all those other intangible things on top of those.  These are the awesome people that can make your like a lot easier.

Additionally, Russell recommends doing international volunteer work if you have the resources. It's very helpful as well as research in plastic surgery being at the forefront of tissue engineering. So there are always labs looking for residents and medical students to do stuff.  There's a lot of data mining right now, which can be a little dry, but you can eventually find your way into something more interesting and surgical. And remember, this boring data stuff that nobody else wants to do it, could be your foot in the door.

[32:40] DO's, Subspecialties, and Working with Primary Care and Other Specialists

Russell thought general surgery was the way he would go, finishing it for five years and then deciding later on if he wanted to do plastics then continue on. The  more he was doing rotations for general surgery and plastic surgery as part of it, the more he knew it was where he wanted to go. Then it went solidified by the time he went to the plastics lab and he finished his second year of residency.

If there were negative biases towards DO in the field, Russell would describe it as rapidly diminishing. One of the strongest sub-I's they had in the program who ultimately did not match into their program, ended up as a major ambassador to this side of things.  Nevertheless, he sees it's diminishing.

So he thinks it never should be a factor in the first place. What he also notices among DO's is they had to work twice to prove these MD's wrong and to dispel whatever biases they have towards DO's and it's unfortunate they have to do this but this tends to be the case.

Moreover, Russell says there's a million of opportunities to subspecialize once you're a plastic surgeon including pediatric craniofacial,  general burns specialist, microsurgery. If somebody becomes affiliated with a children's hospital, they tend to stay very isolated in their pediatric craniofacial. But most people who do microsurgery fellowship for a year will still have to do a lot of general plastics in addition to microsurgery.  There's also hand surgery that overlaps a lot with orthopedic surgeons.  After most plastic surgery residencies and fellowships, you are pretty much qualified to do hand surgery; but Russell happens to do none. But you can specialize all the way up to the shoulders as a plastic surgeon. And of course, there's cosmetic surgery where a lot of people prefer to do strictly cosmetic, which they actually call aesthetic plastic surgery.

In terms of working with primary care providers sending patients to him, what Russell wishes they knew is general health maintenance stuff. Before most plastic surgical operations, smoking cessation (and all nicotine products) is huge more so than probably any other type of surgery because we rely so heavily on blood supply.

Nevertheless, Russell says they tend to be treated well by most primary care providers and other specialties. In fact, he feels like they're “rheumatologists” of surgery; that if they don't know where to send the patients they'd be sent to plastic surgeons.

I would probably approach it another way. I would go into a room of primary care doctors and say, how can I better serve you guys? Plastic surgeons work the closest with general surgeons, surgical oncologists, and dermatologists.  In terms of opportunities outside clinical medicine, a plastic surgeon can do collaboration and consulting on research and product development. On the corporate side of things, you may collaborate with those products you really believe in a lot.

[43:25] What He Wished He Knew and The Things He Likes Most and Least

What he wished he knew before getting into plastic surgery – he wished he would have started saving earlier. He also gives a piece of advice to students thinking about going into medicine – since people can be so quick to tell you to run away and to not get into this – but it's a good life.

What Russell likes the most being a plastic surgeon is being able to help patients in mostly happy stuff. There's not a lot of giving depressing and bad news.

Russell feels extremely very lucky to be able to do what he gets to do. Although there are patients, when you think about them, can give you a lump in the throat; but he has more of a handful of patients that make it all worthwhile. On the flip side, what he likes the least is the idea of people exploiting patients and securities for personal gain with zero concern for the patient's well-being.

At this point, there are a lot of ‘cosmetic surgeons' that are not even in the core surgical specialties or plastic surgeons that are calling themselves board-certified cosmetic surgeons.  They're doing these massive operations in their offices and taking advantage of patients who don't know that there is no such thing as a “board-certified” cosmetic surgeon.

There's no training program for that. That's not recognized by the American Board of Medical Specialties. They're taking advantage of patients. Number one, it's giving any physician who does aesthetic operations a bad name. Number two, it's exploiting people's insecurities and subjecting them to extreme danger. Russell exclaims that this is really very frustrating. He explains that when you see something in the news about a patient dying on the table, it is almost never a board-certified plastic surgeon. It's someone who's typically not qualified and who doesn't know what they're doing, and just trying to grab money, hand over fist, by taking advantage of patients.

Russell says this is very upsetting because it's going on in a deep level and they're usually a very good salesman and not shy about posting things on social media. They would make claims as board-certified plastic surgeons when they shouldn't be; because the Code of Ethics prevents them from making certain claims. But people with less ethics are taking advantage of patients.

[48:55] The Future of Plastic Surgery

At this point, they are using patient's own fat to reconstruct their breasts as well as other areas of the body. There also things like tissue engineering and cellular engineering that ebb and flow. So much of what they do is based on their skill set; so a lot of the technology only tends to be complementary and not just a huge quantum leap kind of things. Many of the surgical advances come from the developing countries. All you really sometimes need is a good microscope and some good hands to do some pretty incredible surgical procedures and lose institutional ethic rules. Nevertheless, he sees the field more of a cognitive innovation versus technical.

[50:20] Final Words of Wisdom

If he had to do it all over again, he would definitely have chosen plastic surgery. He wouldn't think of doing it any other way. As his final piece of advice, he recommends students to ask people who seem to like what they're doing, why they're doing what they're doing, seek out opportunities whenever you can, and do what you can to set yourself apart from your peers; because that's the only way to get ahead but not in a cutthroat sense. Be a good person.

Lastly, Russell gives the same advice he got from his mentor, which is to go where you're needed. Get experience, get good. And then the word spreads and that's how you get busy. Do not give up and do not listen to discouragement. The people discouraging may have met roadblocks you won't even be subjected to. The things that stop them are not necessarily that things that can stop you. They may try to beat you down repeatedly. Just ignore it and believe in yourself.

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