很悲哀? 很現實! 重建(reconstruction)面臨美容傾軋擠壓生存空間的時代終於到來!! 當前輩宿耆們譴責現在的人越來越市儈, 進入整形外科訓練的人大都聚焦於未來的美容市場, 感嘆"世風日下", "今非昔比". Cliche(陳腔濫調)並不能解決問題!!
市場機制不可擋的今日, 必須發展出更良好的醫院制度, 才能因應自費科別(如皮膚科, 眼科, 整形外科等)的"領域重疊", 日見流失重建或基礎研究學術人才的困境. 違背人性的全有全無律, 二選一, 視重建與美容乃水火不容的兩個領域, 是昧於現實&駝鳥心態的策略, 毫無彈性的制度或想法.
(Q2) 面對其他領域醫師(皮膚科, 眼科, 耳鼻喉科, 婦產科, 家醫科, 內科..)的進逼與侵蝕美容市場(甚至重建領域), 有什麼對策??
(Q3) 我們整形外科自己成為拱手讓人的幫兇嗎? 忽略高市場門檻的技術, 擴大非開刀, 另類療法, 低技術門檻的版圖?
(Q4) 未來大家還要像沙丁魚一樣擠在同一個小房間, 小公車裡, 大眼瞪小眼, 汗流浹背, 為生活互相競爭? 負面報導與惡性競爭讓市場緊縮??
茲引用下述 Annals of Plastic Surgery 2004;52:329的一篇文章, 這個困境舉世皆然. 但是路是人走出來的, 重點是要不要解決而已, 可不是Mission Impossible.
Can Academic Plastic Surgery Survive?
Robert L. Ruberg, MD
The next several years will likely be trying times for academic plastic surgery. For a number of reasons, our residency programs are facing a crisis that could have significant adverse consequences for the future of training in the specialty.
There are 3 major causes for the difficulties that are now affecting academic plastic surgery: economic pressures, governmental regulations, and psychosocial factors.
The most critical of these conditions is the current medical economic climate, which is composed of multiple factors: the malpractice crisis, state budgetary issues, and decreased reimbursement for reconstructive procedures.
The costs for malpractice insurance have skyrocketed for many plastic surgeons. Most academic institutions are not insulated from these costs. In my own institution, our malpractice expense has almost tripled over the last 5 years. Of course, there are great geographic variations in malpractice fees, depending on the state of practice of the plastic surgeon. Our Ohio fees are now approaching a per-person cost of nearly 6 figures. We only have to look to the states on either side of us to understand the magnitude of geographic variation. To our east, in West Virginia and Pennsylvania, malpractice costs are even higher than ours, and some surgeons now are having difficulty securing any coverage whatsoever. To our west, in Indiana, the perperson fees are perhaps one quarter of ours. Malpractice costs are obviously affected enormously by the differing laws in various states.
In addition to malpractice costs, the current economy (and its effect on state budgets) can have a significant impact on funds available to run residency programs at state institutions. When the state is having difficulty balancing its budget, its expenditures for education are often one of the first places for cuts. In Ohio, the state has cut funding
for higher education for the last 2 years. Ohio State University passes on cuts to the College of Medicine, and the College has chosen to assign these cuts differentially to the various departments. The clinical departments have received a disproportionate share of these cuts. The rationale for this distribution is that the clinical departments supposedly can make up for the cuts with patient-care income, and the basic science departments cannot.
In my institution, our department has absorbed a 5% cut in state funding for each of the past 2 years. Perhaps we should consider ourselves lucky. One of my colleagues who chairs a plastic surgery program in another state tells me that his department has been cut
40%, and now the institution is beginning to talk about eliminating faculty members with the next cut in state funds.
My colleagues who work in private institutions don’t seem to be subject to the same economic hardship. Furthermore, those institutions that have been fortunate enough (or perhaps aggressive enough) to secure endowment funding for their plastic surgery
programs are not nearly as dependent upon the whims of state legislators.
Perhaps the best plan for preserving the economic health of plastic surgery residencies is to be at a private institution, in a state with favorable malpractice laws, and in a department with a strong endowment base. Sadly, few plastic surgery programs meet
all 3 of these criteria.
The final economic factor is the ever-decreasing reimbursement
for reconstructive procedures. Most plastic surgery residency programs maintain a significant emphasis on reconstructive surgery, both because of the need for a variety of cases to adequately train residents, and because of institutional mandates. In my institution, we are currently managing all burns, all hand injuries, and one-third of facial trauma cases, and we are obligated to care for the prison population of the state. In a large hospital, these responsibilities create a substantial work-load for plastic surgeons, but provide minimal reimbursement.
The average “real world” plastic surgeon can balance a limited number of such cases with a significant number of cosmetic procedures; the multiple obligations of academic plastic surgeons often reduce the cosmetic (ie, well-reimbursed) opportunities. In addition to the economic climate, our residency programs have also been affected by government regulations regarding resident operative coverage. Resident supervision in most of our training programs was perfectly appropriate in years past. Because trainees in plastic surgery had multiple years of operative experience before entering our programs, the residents were often allowed to perform portions of major operative procedures with the attending physicians present in
the operating suite but not necessarily scrubbed at the table.
Overlapping procedures often took place—for example, the
resident could close the breast reduction incisions while the
attending started another case.
Now Medicare regulations mandate that the attending physician be “immediately available” for all “critical portions”of the procedure. In the effort to avoid even the possibility of any violation of government regulations, many institutions have instituted “compliance programs” which interpret the requirements in the strictest possible sense. For example, in my institution, all OR schedules are monitored by our departmental “compliance officers” to be certain that there are no overlapping procedures which could be interpreted as violating the regulations in any way.
In addition, we now have residents with much less operative experience (because total training time has been shortened); these residents require much more staff at-the table supervision when they are operating. As a result of these multiple factors, the number of operative procedures credited to an individual surgeon in any given day is probably lower than it would have been 10 or twenty years ago. Thus the attending physician is working harder and generating less income for the program.
Finally, the morale in many plastic surgery programs seems to be declining. Attending physicians must spend more time in the operating room to “pay the bills” at the expense of time spent in pure teaching or research activities. Volunteer physicians are no longer willing to spend as much time working with residents because of the greater economic pressures in their own practices. Many of my colleagues in
academic programs around the country are very concerned because their full-time faculty members are becoming very disgruntled, and their community surgeons are simply no longer interested in participating in resident training. Obviously, not every residency program is affected by all of the factors outlined above. But every program probably has at least one, and more likely many, of the adverse influences noted previously.
Publicizing these concerns may help bring relief for some of these issues. If organized plastic surgery recognizes that our programs are potentially in serious trouble, then a more formal effort to provide financial and personnel support could be undertaken on a local, or even more important, on a national scale. Otherwise, we are in danger of losing a number of our residency programs, which could have longterm adverse effects on the future of our specialty.
(Q2, Q4) 面對其他領域醫師的進逼與侵蝕整形領域, 有什麼對策??
Innovation: A Sustainable Competitive Advantage for Plastic and Reconstructive Surgery
Longaker, Michael T. M.D., M.B.A..(整形界奇才); Rohrich, Rod J. M.D.
這是Plastic Reconstructive Surgery 2005;1152:2135的一篇文章
Plastic and reconstructive surgeons face increasing competition clinically, especially in aesthetic surgery. Otolaryngologists, dermatologists, oral surgeons, and ophthalmologists, as well as physicians in other subspecialties, are increasingly turning to aesthetic surgery. There is little doubt that the attractive revenue stream from aesthetic surgery underlies the current clinical landscape involving so many different specialties competing in the same arena.
The “discretionary medicine” or “cash business” aspect of aesthetic surgery stands in stark contrast to the eroding reimbursement by insurance carriers for reconstructive surgery. As with any business, attractive margins draw competition, and eventually the supply-and-demand principles of economics will reduce margins.
Given this clinical reality, is there a competitive advantage strategy for plastic and reconstructive surgeons? The answer is yes. Innovation is the sustainable competitive advantage for plastic surgeons, as it has been since plastic surgery became a specialty. It is critically important that plastic and reconstructive surgery residents and fellows understand how integral this competitive advantage is when they finish their training.
It is a daunting and oftentimes discouraging time when a plastic surgeon finishes his or her training and starts a practice. Because of the very nature of aesthetic surgery, it is difficult to build a practice with the stiff competition from other specialties. Simply being a board-eligible or board-certified plastic surgeon does not distinguish our “brand” in the minds of aesthetic surgery patients. While this reality may describe the first year of practice for many plastic surgeons, it stands in marked contrast to the competitive advantage these same surgeons enjoyed as chief residents in plastic surgery. Simply put, the plastic surgery chief resident is probably the most innovative clinical problem-solver in the hospital in which he or she works.
When the neurosurgeon needs tissue coverage or calvarial reconstruction, when the orthopedic surgeon has exposed hardware or bone, when the thoracic surgeon needs help closing the chest wall or when a sternal wound breaks down, when the general surgeon needs help with an abdominal wall closure reconstruction, whom do they consult? The answer is usually plastic surgery, oftentimes through the chief resident. The specialties that compete so aggressively with our recently trained plastic surgeons are usually not the answer for the wide variety of clinical problems that plastic surgery chief residents solve on an everyday basis.
There is a lesson here. Innovation, whether it be clinical or through research, has distinguished plastic surgeons historically and will continue to do so in the future. Innovation for plastic surgeons is analogous to the research and development pipeline of a big pharmaceutical or biotechnology company. We must not forget that innovation makes plastic surgery different and distinctive—the very definition of what strategy is all about. We cannot simply hang a shingle and build an aesthetic practice, because it is difficult to distinguish ourselves easily in the competitive aesthetic surgery arena.
Our strategy should continue to emphasize innovation within plastic surgery. Microsurgery, craniofacial surgery, hand surgery, breast reconstruction, and myocutaneous flaps are examples of how plastic surgery innovation has introduced and advanced clinical care. Most of these innovations were initially published in this Journal, helping to fuel further innovation and refinement in the new field of plastic surgery. Plastic surgeons developed innovative approaches to solve clinical challenges. Driving these clinical advances were research efforts. Taking clinical problems to the laboratory and developing solutions that are translated back to the operating room is the ideal translational research paradigm.
Plastic surgeons should continue to invest time, effort, and resources to maintain a robust, innovative pipeline. Clinical advances in scar reduction and skin remodeling, cell-based strategies for tissue engineering, and regenerative medicine will lead to innovative therapies for plastic surgeons. These new techniques (as well as products) pioneered by plastic surgeons will continue to distinguish us clinically, in both aesthetic and reconstructive surgery. In addition to building large clinical practices, other potential derivatives from this investment in innovation could include intellectual property with substantial revenue streams. In particular, for the Plastic Surgery Educational Foundation, Plastic Surgery Research Council, American Society of Plastic Surgeons, and American Society for Aesthetic Plastic Surgery, these revenue streams could further promote investments in both clinical care and research.
In summary, plastic surgeons should remember that we are innovative problem-solvers and that this differentiates us in a competitive aesthetic market. We must not forget our broad-based training, and we must continue to invest in research that translates into novel therapies. Innovation is our sustainable competitive advantage in a highly competitive and fragmented clinical market. Similarly, our Journal must advance in tandem with innovation in the field, as it has done in the past. That is why we are instituting PRS’ Advance Online, to more rapidly disseminate peer-reviewed information and stimulate further innovation in plastic surgery. Additional innovations and changes in the Journal—both in print and especially on-line—will parallel changes in the specialty as a whole. While these innovations will certainly provide a different look and feel to the Journal, each is primarily intended to be a tool in service to the reader in order to advance plastic surgery. They will enable the reader to receive the most up-to-date information in the most technologically advanced and useful formats. Enhanced videos will provide real-time windows into operating rooms; the traditional method of telling how a technique is done will be augmented by showing how on the Web site with these videos. Exploiting Web publication will not only enable the rapid delivery of information but also provide plastic surgeons with a peer-reviewed forum for a scholarly rapid response to the changes in medicine that are taking place much more rapidly than they have in the past. In the end, as plastic surgeons, we must not forget our roots. Origins matter.