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Plastic Surgery Essay

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Research Paper Outline Plastic Surgery Section – Specialties Recruiting and Retention Fund November 6, 2012 Attn: Mr. Eric J. Harris, Q.C. From: Stan Valnicek, MD, Section Head – Plastic Surgery Dear Mr. Harris Thank you for taking the time to review our submission for the SRRF. We have tried to organize it into logical sections representing the issues that we face as a Section. Our argument is based on data from the following sources: 1. Canadian Institute for Health Information http://www.cihi.ca 2. Medical Services Plan (MSP) BC Payment Information 2010/11 report (Latest) 3.

Survey of our section membership – October 2012 (83% response rate)

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I have included the raw data in the appendix to this submission. We have tried to use the latest available data sets from sources independent to our section in order be fair and accurate in our claims. I am happy to provide all additional documentation and supporting evidence for items in this submission as required. The goal of this submission is to protect the provision of public hospital based plastic surgery services in the province of BC.

Recent media attention in the Vancouver Sun has brought light to the long waits our patients face in the public system: http://www.vancouversun.com/health/Operation+Delayed/7494235/story.html Part of the public issue relates to limited hospital resources in the BC public health care system. Barriers to recruitment are primarily driven by availability of OR time and the willingness of Health Authorities to provide the necessary resources for new surgeons. Low remuneration does affect recruitment in areas of the province that are chronically underserviced since competitive rural opportunities exist across Canada even when major urban areas are well staffed. Our main issue as a section is retention of surgeons within the public system and this is primarily driven by significant intra and inter-provincial income discrepancies that put us near the bottom of all surgical specialties.

Research Paper Outline 0. Definition of Plastic Surgery Plastic surgery is a misunderstood specialty and it is surprising to us how pervasive the misconceptions are among not just the public but also our colleagues in the medical profession. Media portrayals of cosmetic surgery have led to unfortunate distortions and harmful attitudes, which over the years have had significant negative impact on our profession and particularly on remuneration for public work. Plastic surgery as a specialty grew out of the need to address the management of complex wound healing issues in patients with severe burns, spinal cord injuries, major trauma or defects caused by the extirpation of cancers. This is still the core of our profession today. One hundred years ago skin grafting did not exist and even moderate burns were fatal or led to severe contractures and lifelong disability. Patients who had breasts or parts of their face removed spent their remaining lives disfigured and often shunned. Spinal cord injured patients lived with massive bedsores severely restricting their mobility and independence.

Children born with congenital anomalies such as facial clefts were ostracized or worse. Those of us who carry out missions to the third world see the effects on patients and families in regions where plastic surgical care is not readily available. Plastic surgeons have also been pioneers in tissue transplantation, wound healing, nerve regeneration and tissue engineering. Rebuilding form and function has led to the development of entirely new areas such as hand and wrist surgery, facial trauma surgery, craniofacial surgery, microsurgery and skin cancer management.

In the province of BC our plastic surgery section provides the majority of care in the following areas: – Disease and injury to hand and wrist – Disease and injury to the face – Burns – Congenital defects of the upper extremity or face – Reconstruction for defects from cancer ablation – Pressure sores in spinal cord injured or systemically ill patients – Complex wounds – Severe infections including necrotizing fasciitis – Primary cancers of skin and soft tissue – Microsurgical reattachment of amputated limbs or body parts (scalp, ear etc.) – Microsurgical transplantation of tissue – Gender reassignment surgery We are also the 3rd or 4th busiest surgical service (out of 10) in terms of emergency surgery due to our coverage of the majority of hand, wrist and facial injuries.

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Research Paper Outline I. Recruitment and Retention A: Demographics

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Prior to presenting our data, I would like to clarify some of the underlying demographic variables. We presently recognize a total of 81 BC plastic surgeons (defined as those with Canadian certification through the RCPS(C) or international equivalent) within our Section in BC. Some of these are part-time, semi-retired or in primarily private practice. These serve an estimated 2012 BC population of 4.5 million (Statscan 1). In order to determine “full time” practitioners, the Medical Services Commission (MSC) defines a cut off for low billings. This changes yearly and is currently set at $82,100 annual MSP billings or less.

With this metric our numbers drop to 52 active surgeons for the last year data was available (2010/11)2. Government (MSP) plastic surgery census data differs slightly as they include anyone who “bills” primarily out of our section of the fee schedule as a “Plastic Surgeon”. There are about 3-5 of these physicians and may include Orthopedic surgeons with a primary hand surgery practice or temporary locums. For the purposes of this submission, we will use the most current MSP data sets for the following reasons: – they are readily available to the BCMA and to each section. – the BCMA uses them for their own calculations and allocations – any allocated funds rightfully benefit physicians billing out of the plastic surgery section of the fee guide

1 2

http://www.statcan.gc.ca/ig-gi/pop-bc-eng.htm Medical Services Plan (MSP) BC Payment Information 2010/11 report – attached

Research Paper Outline B: Plastic Surgery Manpower in BC over past 5 years

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If one looks at the numbers from the MSP dataset for the last six years, our growth as a section seems significant. I have compared us to all other surgical specialties (9 sections) and medical specialties (18 sections). It would appear that the total number of BC plastic surgeons grew rapidly for 3 years with a leveling off in the last two. 3

18% 16% 14% 12% 10%

20% Plastic Surgery Anaesthesia

8% 6% 4% 2% 0%

Other surgical specialties Medical Specialties

Chart 1: 6 Year Trend in BC Physician Manpower over 2005/06 Baseline looking at total physician numbers per category

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Medical Services Plan (MSP) BC Payment Information 2010/11 report – attached

Research Paper Outline

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When one applies the semi-retired/part-time payment cutoff (set by MSP) to determine the trend in “full time” plastic surgeons, the numbers change dramatically. Here the data shows that despite an increase in anesthetists, medical specialists and other surgical specialties overall, the number of full time BC plastic surgeons has dropped in the last 6 years. 20% Plastic Surgery 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 Anaesthesia

15% 10%

5% 0%

Chart 2: 6 Year Trend in BC Physician Manpower over 2005/06 Baseline looking at full time physician numbers per category

-10%

-5%

Other surgical specialties Medical Specialties

The MSP billing data shows that despite a 17% increase in the number of plastic surgeons in the province over 6 years, the number who bill over a minimum cut-off and would be considered full time has dropped 7%. This trend is in stark contrast to the growth of other specialty groups in BC. The population of BC from the 2006 to the 2011 census grew from 4.1 million to 4.4 million for a 9% increase. Another way of looking at the data shows that in 2005/06 only 19% of BC plastic surgeons were billing under the $82,100 cutoff while in 2010/11 the proportion had grown to 35%. The impact of this on public access to plastic surgical care is enormous.

Research Paper Outline C) Manpower issues related to recruitment and retirement

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Our UBC Medical School has a training program for plastic surgeons. We traditionally produce 2-3 graduates a year. Given a population of 80 surgeons and a career span of 30-35 years one would anticipate needing 2-3 new surgeons each year in BC. The majority (88%) of UBC graduates stay in the province (based on a review of all graduates since 1971) and this is reflected in the rise in total plastic surgeons in BC over the past 5 years. A recent survey of our BC section membership (86% response rate) shows 55% feel their hospital is understaffed for plastics and a further 8.6% call their situation severely depleted. A full 70% of respondents would like to recruit one or more plastic surgeons to their community in the next 3 years. The top three barriers to recruitment were OR availability, cooperation of the Health Authority and low MSP remuneration compared to other provinces. Only 17% felt that availability of suitable candidates was an issue for recruitment.

The important question is this: Why has the number of full time plastic surgeons dropped over the recent 5 year period as shown in Charts 1 and 2 despite growth in all other groups? The answer we believe lays in an accelerating and profound shift in our sections’ manpower and focus from the public system over to the private (cosmetic surgery) sector. D) Private (Cosmetic) Plastic Surgery – Myths and Realities The private or cosmetic practice in plastic surgery has existed since our specialty originated.

Many views about private surgery reflect the situation either in the media (movie/television portrayals of cosmetic surgery) or is based on historical behavior (30 years ago private surgery was the domain of those who had “put their time in” for 25-30 years of active public practice and could now enjoy a more elective pace with less after hours and weekend responsibility.) The private system allowed for more elective daytime work with greater financial rewards and a less hectic pace. The move to a private practice by this group of older surgeons has never impacted the total number of full time surgeons in this province in the past. Something is different in the last 6 years and we are concerned by the changing pattern. It is our position that chronically low plastic surgery remuneration compared to our colleagues is driving our membership into the private system. Unfortunately the perception that we

Research Paper Outline can make up for low MSP payments by simply doing private work has allowed MSP fee suppression to continue and driven more people out of the public system faster than ever.

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The BCMA has effectively handicapped the Section of Plastic Surgery over the past 7 years by including a multiplier in their MANDI (Modified Adjusted Net Daily Income) formula that assumes all plastic surgeons receive 30% of their net income from private surgery. This formula is central to any BCMA attempts at correcting intersectional disparity via the “microallocation” process. Our section feels this assumption is based on inaccurate, incomplete and out of date information and has spent significant time trying to correct the situation. We would be happy to provide more detail on how this has crippled the attempts at fee and income parity for full time MSP plastic surgeons in BC if requested.

The psychological and physical toll of being one of the busiest surgical services while remaining at the bottom of the surgical specialist pay scale has come home to roost. A survey of membership done last month online (65 out of 76 responded) shows that: Most plastic surgeons in BC are engaged full time in the public MSP system 51% feel that in the next few years the proportion of their time private work to public will increase The most common cause for this transition is cited as poor MSP remuneration 34.5% feel burned out often or most of the time 33% intend to retire in the next 10 years Only 40% would advise new UBC plastic surgery grads to stay in BC

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