Enhance Your Practice Podcast
Enhance Your Practice Podcast
E72 WPS Remix: Lessons I Learned From the Trenches
Moderated by Jenni Cheesborough, MD
Panel:
Debra A Bourne, MD
Melissa Mastroianni, MD
Amita Shah, MD
Cristiane Ueno, MD
Thanks for tuning in to the WPS Remix Edition of the Enhance your Practice podcast brought to you by the ASPS Women Plastic Surgeons Forum. We hope you enjoyed our coverage of the WPS Symposium and gained valuable insights from our guests. Remember to subscribe to our podcast, check out our other episodes on your preferred platform or download them directly from ASPS EdNet. Stay tuned for more exciting updates and expert advice to help you enhance your practice.
Speaker 2:Hello and welcome to the WPS Remix. My name is Jenny Cheeseborough and I will be your moderator today. I'm a reconstructive plastic surgeon at the Santa Clara Valley Medical Center in California. I specialize in microsurgical breast reconstruction and have been in practice for seven years. I also get to teach and work with the Stanford University residents as clinical faculty. I'm very excited to highlight four women who gave excellent talks at the WPS symposium this year. Dr Mastrioni, let's start with you. Dr Mastroianni is a fellow Essentials of Leadership classmate and longtime friend. That's a plug for the EOL if you guys haven't joined. She is originally from Wisconsin, completed general surgery residency at Brigham and Women's Hospital and plastic surgery residency at Johns Hopkins. She started her career in academic medicine at Yale, where she built a busy breast practice, including microsurgery, and recently transitioned to a multi-specialty group private practice. Dr Melissa Mastroni will talk about joining a multi-specialty practice. Dr Mastroni, can you give us a brief summary of your talk?
Speaker 3:Hi, thanks for having me, jenny. So for those out there, this is probably not a new thing for people who have already entered practice, but those who are looking to start out in practice and are considering different job models, I think this is something that can be very useful and I sort of wish I had when I was starting out. But here's kind of my lessons learned talked and also I'm just going to say these views and experiences are my own and they might not apply to everybody else, but I still found that different perspectives and different viewpoints on these types of practices may be helpful. So with that I started out fresh from residency two residencies in strong academic institutions Harvard and Hopkins. So I was always really thinking that I was destined to be an academic surgeon. We were ingrained in residency to arrive early and leave last. We were encouraged to seek all cases, extra cases, and value them as beneficial learning opportunities, no matter how tired we were. In residency we were taught and modeled, encouraging completing tasks enthusiastically or at least trying not to complain and to really be a team player. I remember in plastic surgery residency I was sitting there in one of our grand rounds and we talked about the three A's of success in early careers, which is to always be available, be affable and able. And I found that I had a fourth one as well, and that was being adaptable. Fourth one as well, and that was being adaptable. So with that I joined the Yale Plastic Surgery Group and started my career as an academic surgeon and I thought I'd won the lottery. It was great.
Speaker 3:I was a yes person. I was always seeking new patients, especially when referring doctors asks. I tried to be available all the time. I wanted to be the person that people would call because they were in trouble and they needed somebody to fix it. I wanted to be nationally known for the work that I did and I just wanted to be that person who always knew what to do. So I made myself available literally all the time. I was on the phone all the time. I was checking emails and responding to text messages. At the dinner table. I accepted that my add-ons were bumped late because my patients weren't sick, but I was really driven to do amazing work and I still want that, but maybe in a lesser degree.
Speaker 3:But this really took a huge toll on my family. I was rarely home for dinner. I was taking late calls. I was prioritizing my job over my family time and my husband really started to resent me for choosing that. I have two little girls that I wasn't really seeing. It was hard to take vacation. So I remember one of my years I took exactly four days of vacation in one year, and the previous vacations I took basically to prepare for and take my boards fresh after training and it was 2020. So it's not like we were going anywhere and that's how I always justified it, and I found that that was, unfortunately, a very slippery slope.
Speaker 3:I struggled to get going with research because I was trying to be so available clinically and I really struggled with time management and I felt like this really led me to some burnout signs. I had anxiety, I had trouble losing weight, I was not prioritizing self-care and it was clear that this was not going to get any better. So I started looking into what my options were. I could stay at Yale and maybe reduce my effort, and I tried to do that. But after being so available, it was very hard for me to change that and to put up clear boundaries in what I was willing to do and not willing to do.
Speaker 3:I could join a private practice and I started looking around the area for options that might fit me and sort of what I wanted to do, because I still really loved breast reconstruction. I had done a pretty good job of building up my micro skills and I was doing free flaps and implant-based reconstruction. I had a really great groove with my breast surgeon so it was hard for me to think about leaving that. So I wanted to make sure that I had the option to still treat breast cancer patients even if I joined a private practice. I could set up a solo practice, but with two young kids, you know, just starting elementary school, I didn't really want to take that financial risk on or really have to put that much more effort into hiring and firing and learning how to set up a practice. I was kind of looking to consolidate and simplify my life and the other thing was my family and I had bought a house in 2020 and we really did not want to move.
Speaker 3:So after looking at all these options, ultimately I felt like I needed to leave Yale in order to have a fresh start, somewhere to really set my boundaries and stay firm. That way I wouldn't tailspin and overextend myself and basically have trouble saying no. So I ended up finding this multi-specialty private practice group. It was actually it's the New York Bariatric Group and they are the largest private practice bariatric group in the nation. There are 29 bariatric surgeons in New York, new Jersey and Connecticut and they recently took on plastic surgery about seven years ago. So there are three plastic surgeons serving all of those areas as well.
Speaker 3:So I'm in charge of the Connecticut territory. We have three sites in Connecticut and my two partners are in New York and New Jersey taking care of the Connecticut territory. We have three sites in Connecticut and my two partners are in New York and New Jersey taking care of the bariatric surgeons there. We also have medical weight loss specialists and other medical services in-house. So one of the things that the group advertises is you can get cleared for surgery in one day, and that's mostly for the bariatric side. We have nutritionists and everything but like. If I'm at all worried about any of my patients, especially referrals from them, I can just have them follow back up with the team that they've already are used to seeing. So I get plenty of referrals for body contouring, which is great. You know you worry starting a new practice about where are these referrals coming from, so I already had a wait list of patients waiting for me from the bariatric surgeons after the patients had lost weight. So my clinic was busy right away. Plus the fact that I didn't move and I stayed in Connecticut, a lot of my breast cancer patients that I had started reconstruction with were able to come find me and I could finish their journey. And also I maintained that word of mouth within Fairfield County, which is the county immediately adjacent to New York in Connecticut. So that was all very convenient for me and I liked getting busy right away. I am a salaried provider at this point, so part of the practice models that you can join.
Speaker 3:When I was at Yale I had a three-year contract and they started a base salary for me, basically. But there was really no incentive structure built into that contract about bonuses or anything like that. And what I quickly learned at Yale was they were an RVU-based model so I could work as hard as I want on whatever insurance walked through my door and that would be basically approaching my target. So if I did, you know, 100 paniculectomies on Medicaid patients, that would be no different than if I had done 100 abdominoplasties on private pay or self-pay. My productivity would be the same, but that takes a toll as well. One thing I didn't consider is the Medicaid patients may not be as optimized. They may not have as many social supports to help them get through this. So the Medicaid patients do take more handholding and more time usually.
Speaker 3:So with this new practice I'm salaried for three years but I get a collections-based bonus and this may be something that you'll see in contracts. So, for example, if I bring in a million dollars to the practice that's all of my professional fees that I collect from patients which I'm allowed to set then I'm eligible for a 20% of that million dollar bonus for all of the years. The other nice thing about this group private practices they have an escalation or a raise in my salary built in for each of these three years that I'm there. So following this initial period the three years where I'm what we call an associate surgeon not an associate professor, but an associate surgeon I'm basically covered as a salaried employee and that kind of protects an income for me, which was very important because I had young children and actually we just started private school for them and I needed that predictability in my finances. But the other thing is if I want to do some riskier cases or if I'm not busy right away, I'm still paid, which again is important to me just given my circumstances.
Speaker 3:The other nice thing about joining a group private practice is I already have most of the difficult things already in place the hiring and firing. I don't have to worry about it. I have MAs, I have a dedicated PA, I have phone staff, I have you know. Basically I came into a trained office and I didn't have to worry about hiring and doing HR and things like that. They helped me get licensed in three states. I already had my Connecticut license, but now I'm licensed in Connecticut or New Jersey and New York and the group helped me get that in order to provide coverage for my partners. So it's pretty much the three of us. We all take call for our own patients but we cover each other when we're out of town. There are fringe benefits as well, so I can join their 401k with matching and they target a lot of my. They have cover a lot of my marketing, but I'm encouraged to do my own too. So there's a lot to like about joining a multi-specialty group and I've liked it so far.
Speaker 3:But again, this was very important for my circumstances, just given my priorities and everybody's going to have different priorities. One thing I will say is I have been better about setting my own boundaries and keeping them, you know. So when I set up my clinic time, I said I'm not coming in before 9am because I need to drop my kids off at school. And that was fine, you know. And they said do you want to do telemedicine in evenings? And I said no, and that's fine. You know, I'm allowed to dictate all of these, but because I'm not extending myself and making myself overly available and protecting that precious time that I have for other things my family hobbies, research, anything that I would really want to do and I've overall felt the time balance for me has made such a difference in my quality of life.
Speaker 3:So I just passed a year. I am still getting busy and working on building my word of mouth, but overall I'm really happy with my move and I feel better. I see my kids more and this just seems to be a better fit for me. And I will say, along the way, I did meet a lot of people who said you know, don't really count on staying in your first job, and the vast majority, I think, of plastic surgeons do change within their first few years of practice. So I am officially aligned with those statistics but very happy with my move so far. So you know, don't be afraid to make changes, really evaluate your priorities and definitely make sure that you are setting boundaries even early in practice, when you're trying to be available, affable, adaptable, able, all of that. It's super important to set the boundaries in the beginning and stick to them and enforce them, because otherwise it gives an opening for people to come in and change that and push your boundaries all the time.
Speaker 2:So that's my word of advice for people looking into career changes Melissa, you've been incredibly candid and this is invaluable information both for new grads and people considering a change in their career and, like you mentioned, I think the statistics support that most folks in practice within the first five to seven years will experience one if not two career changes. And certainly worth looking into these different types of practices. Just one quick question it seems like you've been incredibly thorough with what you shared, but what challenges did you find in your new practice that surprised you?
Speaker 3:The biggest worry for me was because I'm covering the entire state of Connecticut and, if you could see a map, two of my clinics are within my county but Fairfield County, immediately adjacent to New York, is humongous.
Speaker 3:So really trying to limit my travel so that I'm not trading my call and meetings and conferences at Yale just for driving in a car was a challenge to balance.
Speaker 3:But the company has actually been really supportive of all of that and allowing me to keep that boundary and we're also continuously changing it. So I went up to the Hartford area, which is an hour commute, and the patient population there was a struggle for me to really take care of the way that I wanted to and I said, listen, I just I can't support this from as far away as I am. And they said, perfect, so we've shut that clinic down. I'm now going to two different sites that are closer to me and I feel a lot more confident that I'm closer enough to take care of my patients. So I think just being able to be candid with my employers and telling them what's not working and asking them, those have been challenges for me, just because I still feel like I'm new. But I did find my voice, and I'm happy that I spoke up, because it's a much better situation for me now.
Speaker 2:Sounds like it's better for you and your patients. I'm going to move us to Dr Shah. She is going to talk to us about office management, how to hire and when to fire. She's a board certified plastic surgeon in San Antonio, Texas. She's in private practice at Hill Country Plastic Surgery and is an associate professor at UT Health San Antonio, where she specializes in pediatric burn reconstruction. Her medical school and general surgery training were completed at UT Health San Antonio and she received her PhD in biomedical engineering from UT San Antonio. She completed her plastic surgery training at the University of North Carolina in Chapel Hill, which is a shout out to my hometown. All right, Dr Shah, thank you for joining us from Texas. If you would give us a brief summary of your talk about hiring and firing?
Speaker 4:Hi, thank you so much for having me. So my presentation is about building a team, and I focused on hiring and firing of employees because this is one of those things that happens in the shadows In residency. It's all about whispers of, about residents who come and go, and then also about faculty that's coming and going. Nobody really knows how this happens, and when I started my practice, I was in academics and then I got thrown into it and, since I wasn't in charge, I got to sit back in the beginning and watch all the good stuff. All the bad stuff happen. And sit back in the beginning and watch all the good stuff. All the bad stuff happen. And these are some of the lessons from it.
Speaker 4:I did learn a lot. I got into more administrative roles throughout my academic career and through that then I got the actual experience of hiring and firing people, which led me to opening my own private practice where I'm directly involved with it. This is something that some people say oh, the practice manager is going to take care of this. However, it's really important, especially when it's your own practice, that you're involved with it, because we're the ones that set the culture, we set the tone of it, and if we're not choosing the people that are taking care of our patients, then we've just relinquished a lot of control over who we are. So things that I felt like were key points from my presentation was number one is be slow to hire and quick to fire. That's easy to remember and it really encompasses everything about this. So being slow to hire is this one's. It's harder than you would think that it would be to be slow to hire. So hiring somebody out of desperation is never a good thing, is never a good thing.
Speaker 4:Sometimes the employee will suddenly leave and then we're thinking, especially in small practices, how do we cover this? How do we cover that? And then we hire somebody. That is okay and we are like, yeah, yeah, that's going to be fine, but I have already experienced that that's not the right way to go. It's really important for the team to get the right person. I had an employee leave and actually it was a really critical role and we were trying to figure out my partner. We're trying to figure out okay, what do we do? How do we get somebody? How are we going to make it happen? And it was really wonderful because my staff knew that we were in a bind because we lost that person. And they came up to us and they said we're going to help you, we're going to pitch in until you find the right person. Because they also understood how important it was to get the right person in the job and not just find somebody to do it.
Speaker 4:When you're looking to hire new staff what are specific red flags you look out for? I look out for people who are vague about their responses with things and that are. We ask pretty specific questions about the requirements for the job, and verbal gymnastics is abundant with people who are just trying to get a job. The things that are red flags for us are that they number one the person is not patient or people focused when they're talking about the job. They're focusing on the procedures and all the aspects of the job itself instead of actually taking care of the patient and taking care of the team members. Another thing and this is for any job, not just plastic, plastic surgery but if their first questions are about time off, when are they going to get their next raise or when can they get free surgery and products and treatments, that's a major red flag. And their dnh do not hire.
Speaker 4:Another area that is this is more specific to plastic surgery, especially in private practice they ask for training in areas such as injections and procedures in which they have no training. They are really looking for an MD to teach them how to do this stuff and they may leave on their and go off on their own after they get what they need from you after they get what they need from you, the other things are not willing to cover all the duties and also not willing to help each other and help out their team members. This one is, it seems obvious, but I got tricked by this one before. If they're not familiar with computers, you would think today everybody knows how to do email. But you do actually have to ask this question. There are people who can barely work a computer and in this day and age it's really not going to work unless somebody is completely paper-based On the resume, if they have frequent job changes and they don't really say why they're jumping between practices, especially when they're jumping between plastic surgery practices. And also, if they're leaving a job, ask why they're leaving.
Speaker 4:We've had somebody that left their practice because they were unhappy with something and then they left us very quickly because it turned out they were just using us as leverage to get more money from their other practice. So that was really unfortunate. And number one, a red flag is when they bad mouth others and when they don't respect the chain of command and also respecting the limitations of their licensure and also of their own abilities. An example would be or actually did happen to us. We had an MA that came to interview and then she started talking about her patients, about what all, what the doctor was doing wrong and how she knew better than the doctor and that she's really great and she has so many patients. And we were sitting there just like, oh, oh, my goodness.
Speaker 2:When you're doing the hiring process, do you have like a specific set of questions that you ask that get at their understanding of plastic surgery or their specific competencies?
Speaker 4:So we don't. If they have experience in plastic surgery, that is great, but that's actually not the most important thing. It's really their willingness to learn. So questions that we ask when we're hiring people are what did they do in their previous job and how did it evolve? Because when I see somebody who's able to evolve in their job and shows passion for whatever they're doing and it really doesn't matter what then they are able to adapt, and I have.
Speaker 4:I have employees that are that came from a plastic surgery background and some that did not. And for somebody, for example, if you're hiring somebody to speak to plastic surgery patients about the quotes and things like that, it's actually important that they do have some kind of experience. So I wouldn't hire them for that job primarily, but they could start off in another job with the thought that we could train them to do that. One thing that I have found to be really useful, especially with positions such as receptionist or medical assistants, is what are they planning to do? So I have found that young people that are interested in doing something in the healthcare field. For example, I had somebody that wanted to go to PA school and somebody else that wants to go to medical school and somebody that wanted to be a radiology tech. They were excellent, excellent, excellent employees and I really enjoyed having them because they weren't only there just to get a paycheck, they were there to learn, and I do like to teach, and just because I'm in private practice doesn't mean that I'm pulled out of it. So when we were doing things then I got to the patients, actually really enjoyed it too, because they got to learn too, but I got to show them things and they were excited about doing more than just what they were hired for. So that's another question. I ask what do you plan to do?
Speaker 4:The other question that I think is really important and you can put this in the red flag category is that they need to really know themselves. They have to know what kind of personality they have, what environment do they work the best in and they are okay with uncertainty and change. Then they're good for a practice that has that feel. For example, a startup A startup is going to have lots of changes it's something almost every day Whereas a very established practice. That's better. For somebody who works well with very defined parameters, everything's pretty well. Of course, there's always something that comes up, but things are pretty well set and the doctors are set and it's a bad fit for somebody who gets bored easily, but it's a great fit for somebody who wants a lot of stability and they walk into every day knowing something. Now that same person does not do well in a startup. It's very does not do well in a startup. It's very, very stressful for them. So that's an important question for them during the interview process.
Speaker 2:Dr Shah, I know you gave really great advice during your talk about how to prepare yourself and your staff should a member of your team not be working out. What are some things that you consider if you start to get that feeling that maybe this new hire or established hire is no longer working in the practice, what do you do to prepare?
Speaker 4:So part of preparing is preparing even before you hire the person. So things that are critically important are to do your due diligence on that person first. So we do background checks on every single person and we do call all the references, because some of these things are very well hidden in the interview process, and then we find out during the whole due diligence period. The whole due diligence period and this is also that question that I just answered about the employee needs to know themselves.
Speaker 4:That's where I get a feel of who they are, because the practice that they came from can give an idea of how they work. The other thing is having an employee handbook and policies really well laid out. So this employee handbook is something that we put together. We had our lawyers go through it and make sure everything was within the labor laws and that it could be signed, and something that, of course, any good lawyer can punch a hole into anything, but it would deter usual problems.
Speaker 4:So this employee handbook is handed out to the employee, the potential employee, even before they sign up, after they get their offer letter. Then the offer letter always says that it's contingent on these things and they have to read and sign and agree with everything in that employee handbook. To read and sign and agree with everything in that employee handbook. And this really saves your butt because if something is happening, if they're skirting the policies, you can just say this is in the employee handbook, you got this, you know this and it's in violation of the policies. And it becomes a, instead of becoming an emotional thing, it becomes also just a very practical thing. These are the policies and this is the violation of this. So either we work on this or we work on finding you other options that aren't in this practice.
Speaker 2:I think that brings up a really interesting point. The preparation that goes into developing something like this is enormous, this kind of handbook but it seems like an invaluable resource. We talked about this in your talk back in February but I think it can be hard as the female surgeon in a practice to be both a professional and also friendly and it seems to me that perhaps your handbook is a way of reestablishing those boundaries, is referring back to this handbook. Is that one of your strategies in maintaining those boundaries with your staff as the female surgeon?
Speaker 4:It definitely does help. And in my practice we have a male and a female, so we have a mom and dad it's that also helps. But having that handbook really does help, for example, bereavement it's. I mean, I really do feel terrible when they lose somebody in their life, but they can't be gone forever and the we do have a policy X amount of days and it's there and that way. That's. That's what it is and it's not me making a judgment call. And the other thing is that, because it's written down, we do the same for every single person. So we have to be consistent between all the employees, otherwise there's going to be a risk of favoritism and that if an employee starts saying you're playing favorites, you're doing all this, that's going to really cause a problem and possibly even legal trouble.
Speaker 2:Yeah, let's say that we've fast forwarded past attempting to rehab a staff member, which certainly is valuable in and of itself. But let's say that you've decided that a staff member is no longer working and it's time to let them go. What do you do the day that you are going to fire them? Who should be in the room? Is it an immediate termination? What do you do about security? What's your process?
Speaker 4:When we have an employee that is in the process of termination, we prepare everything before we have the talk with them. Most of the time, the talks can prevent this step from happening. Many times the employee will agree that it's not the best time to go I mean, it's not the best time to stay and they will leave on their own accord. But if we do have to off-board somebody, some of the things that we do before they leave is we review the policies of what they can and cannot bring with them and have a list of it, so we're not chasing after them for something. Once they leave, they're not going to come back. We also secure our technology. So with whatever system you have, if you use Microsoft or Google or some other thing, they usually have litigation hold. So as soon as you know that the employee is going to be fired or if they you know that they have an idea that they're going to be fired put a litigation hold and do mailbox audits. This can save some of the information that they have in their email and can prevent them from stealing things and also from Erasing data that you may actually need. If it goes to the courts, you can pull this data and if there was something on there, then it's saved, even if they try to Erase it. And if they try to erase it, it can be found that they were trying to erase this data, it it can be found that they were trying to erase this data Also have a list of accounts to disable. So the list that we use to onboard somebody is the one we use to offboard somebody, so we can notify the hospitals, we can notify our EMR and our IT person what to disable and also make sure, if we have any keys, communication devices, any kind of records, that they're all secured. Also, we prepare all of the stuff before they're going to leave. So as soon as they say I'm leaving, as soon as they say I resigned or we fire them, then the switch gets turned and we can deactivate everything immediately so they can't just go in and burn everything on their way out. We do change all the passwords. We change everything in the office if we have a keypad, so we can change everything on that too. We make sure all the keys are secured and we know exactly who has a copy of this. If we cannot get some of the stuff back, then everything is prepared for changing out the locks. If the person's leaving on good terms, then we may do an exit interview, but if not, it's not worth the hassle for it and there are also ways for preparing for talking with that employee before they leave.
Speaker 4:I think the most important thing is that termination should not be a surprise. If it is a surprise, then we haven't gone through our process, because the goal isn't to just fire people. It's really that we hired them for a reason, and unless that person was fraudulent and really misrepresented who they were, then there was something about them that we wanted and we thought was good and we want to see if we can salvage that. We should always have a second party present. So we prepare to have somebody, partly for protection too, but have somebody there so they can help document and also witness everything. Everybody that is in administration should be aware prior to the termination. We have cameras in our offices so we need to make sure the cameras are working and if they have the potential to be violent, we don't box ourselves in.
Speaker 4:So if you have a desk, then you sit, that you sit behind a desk and you can't get out of it, then usually the conversation can be shifted.
Speaker 4:So you're in chair. So if something happens where that person does try to attack you, then you're able to get out. So when the employee comes in, the key is to be direct and to the point. So it's not a time for small talk. You just have to go in and rip the Band-Aid off. It's really awkward if you go in and ask about their family, talk about the weather and then say you're fired. So just go in and say this is why you're here and get right to it. If it's appropriate, you can offer options for separation. So if they want to resign in lieu of termination, and for the younger employees, some of them don't understand that this is a better option for them because if they're terminated they actually have to say I was fired rather than say, oh, I was resigned. And it's on both sides. We can say that person resigned rather than they were fired and, if appropriate, then finding assistance and giving them assistance with finding another job.
Speaker 2:These are obviously difficult conversations and I think your tips for preparing for this are invaluable. Is there anything else that you wanted to highlight from your talk? I know everyone was taking furious notes when you were giving your talk at the symposium.
Speaker 4:Yes there is, I think, another part that's really important about curating your team, letting someone go or firing them, whatever you want to call it is being able to do it. It's really difficult to fire somebody and as much as you don't want to make it personal, it is personal for that person and for you. It's not easy. And number one thing is as soon as you identify that somebody needs to go, then they need, you need to do it. Don't wait on it. It just makes it worse and it, it, it muddies up the water. It toxifies, it toxifies the place.
Speaker 4:So one of the ways that I've been able to do difficult things is really look at my mindset and go easier on myself. So one of the things is we may say to ourselves I'm too nice to fire somebody, I can't do this. You push it off on somebody else, but at the end of the day, you're still the owner, you're still the one in charge and you're still the one doing it. So one of the mindset shifts that you can do is um, if you're thinking I'm too nice to fire someone, the mindset shift would be I'm too nice to let this person harm all the other people in my practice who are trying to do a good job and provide for themselves and their family. The other mindset shift is I'm too nice to let this person stay in this job when they could be doing another one that fits their goals and lifestyle and skills better and this one.
Speaker 4:I have found that this one is it's not just a mindset shift, it's actually true. I've seen people leave and go to another place and flourish there. Just because they're not working out at this practice or this job does not mean that they're not going to work out in life. It's just this isn't a good fit. So it's it's a way to encourage yourself and also encourage the other person. It's not, it's not personal, it just didn't work out. And the last mindset shift is I'm not firing this person, they fired themselves. And this is when somebody just does what they're not supposed to do. Uh know that they're misbehaving, they know that they're pushing the boundaries and in this case, sometimes they're not surprised. They're not surprised when they get fired because they know that they've been pushing this issue for a while pushing this issue for a while.
Speaker 2:Thank you, I think. Just in the interest of time, I'm going to move us along to Dr Bourne. Please let me bring Dr Bourne into the conversation. Dr Bourne will talk about women's health and plastic surgery. She's a hand and upper extremity surgeon in Tucson, Arizona. She completed her undergraduate education at Cornell University and attended Yale for medical school. She completed integrated plastic surgery residency at University of Pittsburgh Medical Center, followed by hand and upper extremity fellowship, also at Pitt. Her research interests include the regenerative properties of fat grafting, women in leadership and reproductive health in plastic surgeons. She currently represents the only plastic surgeon and the only female in an orthopedic hand and upper extremity practice and private practice in Tucson Arizona. Dr Bourne, welcome, and can you give us a brief summary of your talk?
Speaker 5:Yes, thank you. Can you hear me okay?
Speaker 2:Yes.
Speaker 5:Okay, so my talk started off discussing some of the personal experience I had with family. I met my current husband as an intern in an integrated plastic surgery residency program and we got married my second year of residency and then I got pregnant my third year of residency, and that was on purpose. I was 33 at the time and I wanted to try to have kids when I was still fertile, and so when I was pregnant I didn't have any serious obstetrical complications, but I was extremely miserable, extremely exhausted, had a lot of nausea and vomiting, and really questioned whether or not it was worth going on with residency. The policy for maternity leave there really wasn't one for our residency program and so I did have the opportunity to take a research year, and I did that because that actually gave me the opportunity to take maternity leave. So I took a research year, had my first baby during my research year, but most of my pregnancy was during my third year, which was a pretty rough year for me and then got pregnant with my second during my chief year, which was a much easier pregnancy. Our call was a lot easier and I wasn't quite as sick. I did have a lot of lower extremity swelling, which was pretty uncomfortable. And then I had him that one month that you have between graduating from residency and starting hand fellowship. So during that one month I took maternity leave and then I was allowed to take three weeks off and still graduate on time for fellowship. So I took those three weeks off and I started fellowship three weeks late and that was difficult because I was breastfeeding during my hand and upper extremity fellowship, where the turnover time is very short, and I was trying to pump in a bathroom, pump in the car pump in my attending's office, just you know, pump as fast as I could between cases and that was actually the most stressful part of my fellowship was trying to breastfeed my child and with that experience I'm very lucky to have two healthy kids.
Speaker 5:And I started talking to other women about their experiences and was really disappointed by kind of what I heard and what I learned and that got me interested in doing research on the topic. So I sent out a survey to all female ASPS members just to see what their experiences were and to see the health implications of being a plastic surgeon and trying to have a family. The response rate was 20%, which is actually pretty high for surveys. We found that the mean age for plastic surgery women for the birth of their first child is over 34. It's 34 and a half, which is not only higher than the US general population, which is 36.9, but it's even higher than other women with a master's education or above. So for them the average age of first child is 30.
Speaker 5:We also found that the odds ratio so the risk of having a miscarriage for plastic surgeons, compared to age-matched US population controls, was almost 3%. So plastic surgeons were nearly 3%, or sorry, three times, nearly three times more likely to have a miscarriage than other women in this country. Even when you control for age, obstetrical complications we found in plastic surgeons was actually 47%. So very high, actually more than double the general US population, which is 19.6%. We also found that infertility was 54% for plastic surgeons, which compared again to age-matched US population. The odds ratio is almost 7%. So again, seven times more likely to have difficulty conceiving and carrying a pregnancy compared to our you know, other American women.
Speaker 5:Then we looked at breastfeeding. We saw that the mean period of breastfeeding was 7.6 months. It's recommended that women breastfeed for six months after having a child exclusively and then continue for the first year with other complementary foods. We found that plastic surgeons, 37% breastfed for less than six months and 75% less than 12 months. And then we looked at maternity leave and the mean maternity leave was six and a half weeks, but 40% of women took less than six weeks, and six weeks is the recommendation by the American College of Obstetrics and Gynecology as far as the minimum parental leave to take after the birth of a child, as far as the minimum parental leave to take after the birth of a child. So all these findings are pretty shocking.
Speaker 5:And so kind of finding these things so plastic surgeon females have higher risk of infertility, higher risk of miscarriage, higher risk of obstetrical complications, compared to other women in our country at the same age, you know, kind of leads me to say what are we doing wrong? What can we do to change things? And so you know there's a lot of things that go into this, but some things that we can sort of work towards are things like having comprehensive leave policies for hospitals, residency programs and even private practices. It's amazing that plastic surgery was the first board to allow residents to take 12 weeks and not be penalized, still be able to graduate on time, still sit for their boards, and that has been a huge step and I know a lot of residents have been able to take advantage of that. Coverage for infertility should be part of our health care benefits.
Speaker 5:Developing an educational curriculum, both in medical school and in residency, that educates women and men about the health challenges of being pregnant and carrying children as a plastic surgery resident and sort of helping people sort of plan and know what the risks are, and then having lactation facilities that are close to the operating room, close to clinic, easy and fast to get to so that you're not pumping in a bathroom, pumping in your attending's office.
Speaker 5:You know it's a very awkward situation when you don't have good lactation facilities and then having a supportive work environment. So one other thing we found in our study was 68% of women agreed with the statement that there's a negative stigma associated with being pregnant and being a plastic surgery and being a surgeon. And so dealing with that negative stigma and dealing with that sort of unspoken or behind your back sort of comments that if someone's a parent and a female, that they're spending more time worried about their family, they're not committed to their career, that it's going to impact their ability to be a competent and caring and hardworking surgeon, fighting against that sort of mindset, fighting against that sort of mindset.
Speaker 2:I think your study is incredibly valuable and, like you, I've seen I've lived through the change. I did not have the benefit of a lot of these policies that have been enacted when I was in training, but I'm so grateful for the female trainees behind me and the male trainees. It's actually really nice to see the young men take time with their young families too. It normalizes time off around the birth of a child or adoption. I want to make sure that whatever surrogacy, adoption or birth those are all supported and should be important. You mentioned in your comments that we need to educate female residents about how, like what, to expect being pregnant. As a trainee, I'm actually really curious what we can do to support our fellow female trainees and surgeons in ways to be safe while pregnant. What do you think about timing for when people should stop taking call, when they should stop working perhaps? How do we support women so that we aren't having premature births as a further complication?
Speaker 5:Yeah, I mean, that is a great question. So we do know that plastic surgery females have a much higher risk of low birth weight and preterm labor, and we also know that long periods of standing and longer work days and taking call and stress are all risk factors for that. Anything that's not good for you when you're not pregnant is even worse for you when you are pregnant, and we all know that sleep deprivation is bad for you. Um, stress is bad for you, and then you add the stress of being pregnant on top of that and it's really pretty toxic. I don't know that there is a set timeframe for when we should stop women from taking call. I mean, to be honest, when I was pregnant, I was most miserable during my first trimester. Most people didn't even know I was pregnant then, and that's actually when, like, the most critical development period is.
Speaker 5:I think it's really important that residents be aware, if they're using the C-arm, that they need to have pregnancy led and that they need to go to the radiation office and they need to get a separate monitor for the fetus, and they should be doing that really early on, even before they tell people that they're pregnant. So that's something people need to do to protect themselves. And then we also found, you know, 10 percent of women were put on bed rest, and I think that's just the ultimate the the obstetrician saying you cannot live this lifestyle, you need to be put on bed rest. I think it would be nice if we could figure out a way to give all of our residents a lifestyle that's not bad for them, whether they're pregnant or not, where they're able to sleep reasonable amounts, and I think they would treat their patients better. It's just a matter of not having enough workforce.
Speaker 2:Yeah, I understand exactly what you're saying about the need to make sure that we're continuing to provide patient care, and that comes sort of with that service education discussion that we always have. I just extended to also it's our female faculty colleagues, it's. You know, as we've extended the age at which people are having their children, it's not unusual for our fellow female faculty to be having children into their 40s. So, as advanced maternal age already is a factor for those folks, we want to make sure we're protecting them too. I think there's still a lot of work to be done in this space and I really applaud your bringing this very much into the light as a topic that needs to be further discussed, and I appreciate that our colleagues on the board are working towards ensuring that residents can take the time that they need to recover from having a child and also spend some time bonding with those children. So I think we're making strides in the right direction, but certainly have work to do.
Speaker 2:Chris, dr Ueno trained and practiced plastic surgery in Brazil before coming to the United States. She completed general surgery and was a junior resident of Dr Amita Shah, who we just heard from. Then she graduated plastic surgery at Indiana University. She was the service line chief for plastic surgery at Kaiser Permanente in Washington and about three years ago Chris joined the Department of Plastic Surgery at the Ohio State University, where she is an associate professor and the associate program director for the plastic surgery residency. Dr Ueno will talk about second victim syndrome how your patient suffers and then you also suffer with them. Chris, will you give us a brief summary of your talk?
Speaker 6:Yes, thank you so much for this opportunity. I think it's really great, and this talk stemmed out of a conversation with Ashley in one of the WPS meetings was when I was at Kaiser. I had a week with lots of not lots, but with some bad complications out of surgery. So one was a non-binary patient physician that trust that I was, among the plastic surgeons, the best one to help them with their mastectomy. So unfortunately they developed a hematoma and the PECU had to go back, had to go back to the operating room and then later on ended up developing a pneumothorax.
Speaker 6:So it was like a bad sequence and that made me think about what, what I? What was like plastic surgery, should I be doing this? And I wrote a letter to one of my friends that is like an old school and likes letters. He immediately called me and said crazy, if I didn't know you I would think that you would commit suicide. And I was like, oh my gosh. So then I started looking and basically I think we're so used to make you know, have a bad outcome and then really suffer in silence. I think that you know I'm studying now and doing my MBA and I'm the only physician in my group BA, and I'm the only physician in my group and it's so funny that I think we are like so used to somewhat beat ourselves down, right, that's the old school M&M, so I think we don't really realize how much this can affect us.
Speaker 6:So second victim means the first victim is obviously the patient and their family, but then there's this knock-on effect and then you're the second one, right, you're feeling for the patient that had a bad outcome, feeling for their families and what this means and what this means. And then, looking in numbers, the prevalence of second victim varies between 10.4% to 43.3% and, amazingly enough, female surgeons in general, they feel more distress when they have a bad outcome. They are more afraid of losing confidence, more concerned about receiving blame from their partners, and they experience more loss of reputation from their colleagues than the male counterparts. However, on the other side, female surgeons are more motivated to discuss the errors and the bad outcomes and help others. The other part that is interesting to me is that I work with residents, right, and we as surgeons, providers, attendings faculty, we have the second victim kind of syndrome happening, but we forget that our residents feel the same and I think for them there's that it's kind of like a double effect. It's guilt in regards to the patient that suffered, but also they have this anxiety of like how are they performing and how we're perceiving them. Moreover, they fear more for their future because they will need letters of recommendations. They never had a job. It's just going to affect them, and I think we need to be very conscientious about it because this can have a much longer lasting consequences on residents. There's some research studies that showed that 86.5%, which is a huge number of residents, have some emotional sequelae secondary to the second victim syndrome.
Speaker 6:One thing that is important to point out is that second victim syndrome has stages. The first stage there are six stages. The first one is a little bit of chaos. You're trying to go through the motions of what happened and then, after that, comes a reflection. You start to replay that event in your head multiple times and you start thinking that you're not good enough. And then, after that, you start to restore your integrity, kind of like you know, become together. And then that's when you go and look for someone, someone that you trust, to kind of like tell them what happened and see if they can show you a different lens. Right, and I think for that part. It's important for us to recognize, when we're looking for the person, but also when someone is looking for us, that this is a very difficult moment and I think it depends on how the other person reacts. That can spiral into a negative or a positive experience.
Speaker 6:So I think when, in general, people have a positive and supportive environment during this phase, it's much easier for them to move to a more positive outcome. So then the next phase is like you start to think about the repercussions of what happened. Am I going to lose my job? Is it going to affect how the others perceive me? Is this going to affect my license? Should I be worried about future litigation? What is the organization going to think about me?
Speaker 6:And then, after that comes a kind of like, you start to look for some colleague, someone that is around you, practices with you, for an emotional support and, similarly, having a supportive environment extremely positive, um, it helps you inspire in a good way, because from that stage is like the moving on stage, and the moving on stage has three possible outcomes.
Speaker 6:One is dropping out. You just feel that you're not enough, you feel like you failed, and then it's better if you move to another place move to another job or quit your job, quit medicine, quit it as a whole. There's a second possibility, that is basically surviving. You're sad but you try to cope with this, try to learn from this event and basically move on. But you have safer initiatives and try to learn from that and make a difference for the next patient, make a difference for the other clinicians or providers that you know that may be suffering from that. So those are kind of different outcomes and I think for us it's really important to understand this, be aware of the resources that are around us and then understand that we need to support each other and fortunately there's. Women face in general, more negative emotional and professional outcomes than men and it's definitely more pronounced in females that have more family responsibilities. So supporting each other, building systems that encourage this type of support, I think is extremely important.
Speaker 2:Chris, a question. I know my first instinct when I have a complication is I want to hide, I want to run away from it. It's my worst instincts and I've learned to address that. In fact, I've learned when you have a complication, those are the patients you want to see the most. But with that initial instinct to just want to wish it away, sometimes that comes you've mentioned, it's very isolating and I think in surgery, especially once you've left an institution where you have something like M&M to discuss this in a formal scenario what would you recommend for our colleagues who are more in solo practice or in a small group practice where they don't have a formal process for discussing these complications? But, as you mentioned, it's so important that we do both to learn from and to heal from.
Speaker 6:That is very interesting, jenny, because I think M&M has it's kind of like a double sword, right, because it has that healthy discussion where you kind of go over the whole process with your partners and a group of people and you think about, okay, what can I do different? And then have a positive outcome and grow from there, right, but also has, like it depends, you may also experience the negative side, right. Oh, I knew you would have this complication, you know, and someone really beating you down and just making it worse. So what I can say is remember that you're not alone. And then, unfortunately, everyone will have a bad mistake, and it can be.
Speaker 6:It doesn't necessarily need to be like a surgery, like a surgical. It can be a medication, you know, it can be an advice. And then it's hard. You totally feel that you're the lonely one, you feel very exposed, you know, and you keep replaying this over and over in your head. But I would say just remember that you're not alone. Unfortunately, you know things happen. But the most important thing is try to grow out of this and see the other positive side and how can you prevent this to happen to others. And then that's how you learn, that's how you thrive and obviously identify partners, colleagues that can actually don't need to be in your specialty and that can actually don't need to be in your specialty but can actually understand how you're suffering and then, you know, bring you up and elevate you as well. When I was in West Virginia we're a very small group we had like three plastic surgeons and my best friend for this discussion was a surgical oncologist.
Speaker 2:I think it's a wonderful opportunity to have friends in other surgical specialties and, like you, my person is a trauma surgeon who is a friend from residency, and there are days where she and I just commiserate about our challenges, but it is valuable to have someone who knows you, knows your heart and knows that you're always trying your best and that you're right. Not everyone can be perfect every day, chris. Is there anything else you wanted to share about your talk on second victim syndrome?
Speaker 6:No, I would say just be aware. Be aware of the phases and the stages that you go through. I think we are all in medicine because we love what we do. Try, you know, don't feel bad that you're, don't feel that you're a failure, Don't feel that you don't belong and drop out. Similarly, try not to just be sad and just say I got to suck it up buttercup, and just keep going. Really you're not alone. Just keep going. Really you're not alone. There's lots of other people like we're just talking about, that went through. You know, WPS is a great way. Lots of people that can support each other. It's a very positive environment for everybody. So, look for someone, look for a mentor. We're all here, we all want to help and, as I said, we all have a list of names that we will never forget. And just really do what you love and we're here to support.
Speaker 2:Thank you so much to Drs Mastrioni, shaw, bourne and Ueno for sharing your thoughts and expertise. You all gave thought-provoking and revealing and very candid talks on challenging topics and I thank you.
Speaker 1:Thanks for tuning in to the WPS Remix Edition of the Enhance your Practice podcast brought to you by the ASPS Women Plastic Surgeons Forum. We hope you enjoyed our coverage of the WPS Symposium and gained valuable insights from our guests. Remember to subscribe to our podcast, check out our other episodes on your preferred platform or download them directly from ASPS EdNet. Stay tuned for more exciting updates and expert advice to help you enhance your practice.